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Applications Will Be Processed When Submitted Properlycompier qjepure-1oalgr, 1rl� n� <br /> F R OFFICE USE: APPLICATION Oo <br /> (For Non-Transferable, Revocable, Sus able) v 4 0 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT A� JOAQW� 4 LOCAL <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY DIS-rRICT <br /> }->rL�H <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermittoconstruct and/orin a the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Jotagguip Local Health District. <br /> Exact Site Address 4148 Waller Rd, City/Town KOri <br /> I <br /> Owner's Name <br /> Ernest Riley Phone 9 3 J—96 � <br /> Address swne City d <br /> Contractor's Name Moorman r s Water S ,StemS License# 267-6D6 Business Phone933 —321 0 , <br /> Contractor's Address 243 Cheraryland AVE. Emergency Phone S e <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❑ <br /> 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 2_1. <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 moorman I <br /> Type of Pump Simmers e H.P. 'z „ <br /> PUMP REPLACEMENT: ®'State Work Done Replaced existing pum with 3'HP <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I 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 following:"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 c II for a Grout Inspection prior to grouting and a final inspection. ` <br /> Signed X �irc2- �7–� Title: Date: a"` <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By tXY' 1� Date _' =.— <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III Final 19Wection <br /> inspection By LIAM I Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No suaficd Dae Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. <br /> t <br />