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AIpI]�Hons.bWWI Be P ageSs d Wth ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: 13V APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) PUMP&WELL <br /> A I SAN,,bq� 'tt✓ ONMENTAL- HEALTH PERMIT�2 III HEALTH <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or.install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance_ND. 1862 and the rules and regulations of the San Joaqujn Local Health District.. <br /> Exact Site Address 12-A,Sq Cadel 'RACity/Town Lodi, <br /> Owner's Naive r, Phone'� <br /> Address Ij :;I _ City'* <br /> Contractor's Name I C k)r-� °' License#� B siness Phone=`CD2 142 <br /> Contractor's Addres5,P"^t� t adt ftL Emergency h re <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No W <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITIONe 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 ' <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 <br /> Type of Pump W.P. <br /> PUMP REPLACEMENT: State Work Done Qa2- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> 1 hereby certify that l 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 �J <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 forwhich this ' <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> a <br /> I <br /> ill r a Grout Inspection p ' r gro ung an final inspection. <br /> Signed X y _ . Title:.-t - `Date: r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI A <br /> Application Accepted BYA <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection se 141 F' ection <br /> .Inspection By,�__� �. Date Inspection By e - <br /> If <br /> Fee Is Due: ❑ ANNUALLY " . ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31" ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE` EXPLANATION DAMOUNT DUE CHECKED' <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE 'T� . <br /> LESS Y <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - - <br /> J� a513 ( 6Y <br /> Received by Date Receipt No. - Permit No, Is ante IDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE_,P.O.Bo:2009 STOCKTON,CA 95201 <br />