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FOR OFFICE USE: 42 APPLICATION <br /> L (For Non-Transferable, Revocable,5uspendable) &NWA <br /> ED <br /> ;;`1,'Inb 1aW�f ONMENTAL HEALTH PERMIT <br /> TI- :-,--< <br /> ' }t,1 j".:-j. ylt S IG WATER QUALITY <br /> (COMPLETE IN TRIPLICATE] <br /> Application is hereby made to thMan Joaquin Local Health District fora permittoconstruct and/or install the v6rk herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 11 204 _ B aker R City/Town <br /> Owner's Name Phone 931_5496 <br /> Address same as above City c..-r...kto <br /> Contractor's Name Moorman 1_ s Water System_ License# 2657 696 Business Phone 931-3210 <br /> Contractor's Address 7J g Tdi 1 c!nx Rd Emergency Phone ` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 18 <br /> i REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor MOprMan r g Wa-ter S%Y at <br /> Type of Pump t-kkrhi pp__ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: W State Work Done E. �• 1 d <br /> DESTRUCTION OF WELL: Well Diameter Appro (mate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"l certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed XI(�r. ' <' ,�r� � Titley ' -,%�J ._ .. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ByDate <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase_.11l Fin I Inspection r -:: <br /> Inspection By Mick Date Inspection By k ✓�C'�C gate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE 5 <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> i � AMOUNT <br /> 4 FEE � <br /> LESS <br /> PFIORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> '56 <br /> �Receivetl 6y Date Receipt No. Permit No. &uancei Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENv1RONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P-O.Box 2009 STOCKTON,CA 95201 <br />