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gA tiq #�l2p e ubmitted Properly Completed. Be Sure To SignTheApplication. <br /> /OR OFFICE USE: rl{�s - APPLICATION , <br /> (For N ansterable, Revocable,Suspendable) <br /> SEP 8 19%NVIRONMENTAL HEALTH PERMIT pLr &WELL <br /> (COMPLETE IN TRIPLICAT WATER QUALITY <br /> qJ,J��Anl11 <br /> Application is hereby made t%J , <br /> R! L�a��FF��ifR�istrictforapermitloconstructand/orinstaNfheworkhereindescribed.Thisapplicationis <br /> made in compliance with Sat4t)n pafIFgQTNo. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addl$1233 N. Eberhard Rd. City/Town Lodi <br /> Owner's Name Derald Goyette Phone 931-4422 <br /> Address Sallie City CA <br /> Contractor's Name Moorman r s Water Systems License#267696 Business Phone912-1210 <br /> Contractor's Address 4243 CherrylandEmergency Phone <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 71 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 /> :E1 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 Cl ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> Type of Pump submersible H.P. 5 W <br /> PUMP REPLACEMENT: 12 State Work Done replaced existing PUMP With new 5HP <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 /> 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 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 /> j <br /> Iwill call for a Grout Inspection prior to grouting and a final inspection. ,� (� <br /> Signed X 0,21.1 el_ ��7i ��' -1-1/ Title: fir CY_ J Date: <br /> 61- (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE F� <br /> Application Accepted By V Date <br /> Additional Comments: <br /> e 11 Grout Inspection Osft Final Inspection ,�"' Q <br /> Inspection By Date Inspection By Date Lel U�fS� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> 4 d <br /> FEE <br /> Lie <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 o <br /> Received by Date Receipt No Permit No. lisuance Datel Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20119 STOCKTON,CA 95201 <br /> J <br />