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Will Beations Processed When Submitted Property GvmPraiaW• --- - - <br /> Applications <br /> t .�. <br /> PPLICATION <br /> /Application <br /> FiCE USE: r f.�*�a f ye`abler evocable,Suspendable) J "PllMp&WEAL <br /> RNVI+RONMT � H PERMIT <br /> ATER QUA <br /> TE IN TRIPLICATE) alth Districtfritt tructand/or install the work herein described.This application is <br /> is hereby made to the San Joaquin LOIi1�itH`l��rr 62 and the rules and regulations of the San Joaquin Local Health Distrlc . <br /> maompliance with San Joaquin County Ord �ihcdB��V, a City/Town LOd I <br /> Exact Site Address�2 1 2 Cheri-, 5 f r .R1C; � phone (209) 334-563 + <br /> k Cit of Lodi Clty Lod i <br /> Owner's Name _ <br /> l Address ine License# �?125- Business Phone <br /> Contractor's Name Luhdorff Co. <br /> r Emergency Phone <br /> Contractor's Address X No <br /> G Is Certificate of Workman's Compensation Insurance on File With SJL pI�1D1710N® DESTRUCTION❑ <br /> TYPE OF WORK {CHE K): NEW WELL❑ DEEPEN <br /> WELL CHLORINAT N 11 WELL ABANDONMENT ❑ OTHER [3 PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> ) REPLACEMENT __ Sewer Lines ) Pit Priv y <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field -Private Domestic Well Public Domestic Well <br /> Property Line <br /> _ <br /> _ I— <br /> '-- <br /> € 20TYPE OF WI=LL <br /> l INTENDED USE Dia. of Well Excavation <br /> ❑ INDUSTRIAL ® CABLE TOOL 1411 <br /> I, ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE [] DRIVEN Gauge of Casing I C <br /> t ® DOMESTIC/PUBLIC Depth of Grout Seal <br /> ❑ GRAVEL PACK cement �6 Sack a <br /> I ❑ IRRIGATION El ROTARY Type of Grout <br /> 1 ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Doned%1 PUMP REPAIR: Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: � <br /> Describe Material and Procedure. <br /> j 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 /> eto become subject <br /> Homeowner 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 <br /> such <br /> manner <br /> certifies following,I certify that in th an's compensation l performance of thework forwaws oflh ch this <br /> Contractor's hiring or sub contracting signature <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 4 <br /> I will call for a ut inspection prior to grouting and a final inspection. Date: �S <br /> Title: Gift} —`J <br /> r Signed X - -,(Draw Plot Plan on Reverse Side) <br /> f F R DE ARTMENT SE ONLY <br /> PHASE 1 Date <br /> Application Accepted By <br /> Additional Comments: p db III Final InAspection <br /> Phase Grout 1 spection la <br /> Date '3 � Inspection By Date <br /> Inspection By �� Yi <br /> Fee Is Due: ❑ ANNUALLY ❑ PFR UNIT [)rPER E F-1EACH J ElJanuary i &Received 8y January 31 "El July 1 &ReceiveRdEMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT <br /> i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHFR <br /> ' ✓'� <br /> r �Permit No. Issuance Date Ma'sled Delivered <br /> Received try Date Receipt No. - <br /> MITlSERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER <br />