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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFF4CE USE. APPLICATION <br /> �,. A (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cotjr ty Ordinance No. 1862 and the rules and regulations of the San Joaquin toe'Health'District. <br /> Exact Site Address 8008 E. West Ripon Rd. City/Town Manteoa `' ' <br /> Owner's Name Jim Moorman Phone 239-1198 t <br /> Address 528 Oregon St. Manteca City Mantgaa <br /> Contractor's Name _Moorman r s Water Systems License#267696 Business Phone <br /> 931-3210 <br /> Contractor's Address 2120 WilCox Rd. Emergency Phone x <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 L Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL lZ�� <br /> 11 INDUSTRIAL ❑ CABLE TOOL- Dia. of Well Excavation <br /> f <br /> DOMESTIC/PRIVATE Rkl5RILLED Dia. of Well Casing D <br /> ❑ DOMESTIC/PUBLIC © DRIVEN Gauge of Casing <br /> ❑ :IRRIGATION ❑RAVEL PACK- Depth of Grout Seal Q <br /> ❑ 'CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Otfierzlnformation / <br /> ❑ GEOPHYSICAL Surface Seal Installed By: .G f n <br /> PUMP INSTALLATION: Contractor Moormangs Water systems <br /> Type of Pump— suhmersibla H.P, 1 <br /> PUMP REPLACEMENT: ❑ State Work Done— <br /> PUMP REPAIR: ❑ State Work Done O <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 /> I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> 1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will' II for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Tlue: Co—Owner _ Date: 2-8-82 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ih , p <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspectionp Ph se III Final Inspection <br /> Inspection 8 bate Z�Z� - 0 �— Inspection By Date �- 11-d -L— <br /> Fee <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE E <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. _ Iss ante Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />