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Applications Will Be Processed When Submitted Properly Completed 'e�tjre-Tosign TneAPPEICZEW <br /> I APPLICATION l p <br /> FOR OFFICE USE: I <br /> f (For Non Transferable, Revocable, 5usp111e) <br /> I. �4r&WELL <br /> = ENVIRONMENTAL HEALTH PERMIT ! <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYS� pp,I -14 <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or inlet_he 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 Joaquin Local Health District. <br /> Exact Site Address 066 N. Davis Rd. City/Town Lodi <br /> Owner's Name Ji B kner Phone 466-202 <br /> IE <br /> Address 1675 W_ C'ha �€cr W��7 City _ t0 T] <br /> Contractor's Namer S License#267696 Business Phone 931-3210 <br /> Contractor's Address 4243 <br /> " lan nsu __X_Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes � No <br /> r' TYPE OF WORK (CHECK): VIEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑, <br /> WELL CHLORINATION ❑ WELL A13ANDONMENT El OTHER 13 PUMP INSTALLATION ElPUMP REPAIR�I I <br /> REPLACEMENT❑ f rVr'J <br /> DISTANCE TO NEAREST:. Se.ptic 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 i TYPE OF WELL <br /> ❑ INDUSTRIAL I ❑ CABLE TOOL Dia. of Well Excavation <br /> ,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> !. ❑ DOMESTIC/PUBLiC I ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL i ❑ OTHER Other Information <br /> 13 GEOPHYSICAL I Surface Seal Installed By: <br /> ' tems <br /> PUMP INSTALLATION: ' I Contractor Moorman' Water S s <br /> Type of Pump_ e H.P- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: --"" ---"'"'� State Work Done Ott 1 7 � •. rewired as necessary_.re-install. <br /> DESTRUCTION OF WELL: — I Well Diameter Approximate Depth <br /> �I 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 /> and rules and regulations of the San Joaquin Local Health District- <br /> ordinances, state laws, 9 _ <br /> I Home owner or licensed agent's signature certifies the following."I certify that in the perfo"rmance of the work for which this permit <br /> F 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 slI all employ persons subject to workman's compensation laws of California." <br /> ` ;Ij <br /> I ;;1Ifor a Grout Inspection prior to grouting and a final inspection. <br /> Signed X ll /! Title:ry Date: 5 97a <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> L" PHASE I <br /> I Application Accepted By-' <br /> Date <br /> t Additional Comments: I��I <br /> Aase II Grout Inspection P s III Final Inspection <br /> Inspection 8y_� Date inspection By Date 7-Z <br /> Fee Is Due: ❑ ANNUALLYII ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. _ ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATREMITTED E AMOUNT <br /> FEE <br /> r <br /> LESS <br /> PRORATION II <br /> If PLUS <br /> PENALTY <br /> OTHER 11 <br /> ` OTHER ��II <br /> � <br /> Received by bate Receipt No. Permit No- Issuance Date Mailed Delivered <br /> APPLICANT—RETURNALL'COPIESTO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES,•^ <br /> 1601 E.HAZELTON AYE.-,P-O.Box 2009 -STOCKTON,CA 95201 <br />