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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The kp�f�tlon. FOR OFFICE USE: APPLICATION j a3 (For Non-TmStable,Revocable,Sgapendabi�) .0<)NMP&WELL ENVIRONMENTAL HEALTH \PERMIT, ,\ 11� OL�4 MPLETE IN TRIPLICATE) WATER QUALITY plication is hereby made to the San Joaquin Local Health District a permit to construct and/or ins`alKlie�rkvemin described.This application is made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulatiolssibf �e1S8n Joaquin Local Health District. Exact Site Address 277 N. Sibley Cityhhlrn Storktnn Owner's Name Tony Quintel PhoneTyysY' Address S m City Contractor's Name Moorman s a Water Systy�_mS License# 967696 Business Phone 911_4 91 n Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No TYPE OF WORK (CHECK): NEW WELL-a DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ G WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX4, PUMP REPAIR❑ . REPLACEMENT❑ f� 1 It DISTANCE TO NEAREST: Septic Tank. [I Q l Sewer Lines. �/ t Pit Privy -. Sewage.Disposal Field 6esepaal/Seepage Pit Other Property Line/0-±-Private Domestic Well Public Domestic Well INTENDED USE `i TYPE OF WELL Z/y�G )_ 11 INDUSTRIAL ❑ CABLE TOOL' + Dia.of Well Excavation 4 DOMESTIC/PRIVATE DRILLED Dia. of Well Casing 4 1/"DOMESTIC/PUBLIC 9 DRIVEN -.1 Gauge of Casing i2,2 ✓L ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal il J ❑ CATHODIC PROTECTION ROTARY Type Of Grout ❑ DISPOSAL OTHER Other Information �ssJ ❑ GEOPHYSICAL Surface Seal Installed By: 4 Y r' Mile PUMP INSTALLATION: Contractor Moorman'3 Water Systei Type of Pump RubmLzrsihl a H.P, 1 PUMP REPLACEMENT: ❑ State Work Done ,MMP REPAIR: _ 13 state Work Done TRUCTI ON OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following,:"I certify that in the performance of the work for which th is permit is issued; I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I.shall employ persons subject to workman's compensation laws of California." - I will call for a Grout Inspection prior to grouting and a final inspection. Signed X _ r�� Title: &P -4J24tn ✓ Date:LT (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By - Date Additional Comments:- , �e II G�jut Inspection �Y 3 �? se III In 1 Inspection By_� !/'�t-- Date /�J .7 Inspection By DateLi[rl�= Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 R rved By January 31 ❑ July 1 a Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT.DUE \ CHECKED DATE DATE REMITTED 'Q AMOUNT 0 L) rd FEE . (J LESS PRORATION PLUS PENALTY off K-4 OTHER OTHER Received by Data Receipt No. Pe t No. laeuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SER CES 1801 E.HAZELTON AVE,P.O.fax 3009 STOCKTON,CA Satin