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Kp'fAi ations Will BePiroiiiliss�ddWhehn Submitled Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: li1j"iAPPLICATION <br /> 5 For ransierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> �'� .f',"��;rf ENVIRONMENTAL HEALTH PERMIT <br /> F. 4 <br /> 1 <br /> (COMPLETE: IN TRIPLICATE)�t f;? ' ��� �l WATER QUALITY (JZS- l `f n-3 <br /> ��l�1n `' <br /> Application is hereby made to the San Joaquin CocaiPealth District fora permit to construct and/or install the 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—Aalrth-end Of FreeRo.ad on West c j_de City/Town —I odi_ <br /> 15'7 7-,[ /0 •f '"' <br /> Owner's Name Norman Swanberg Phone J_ 68-3596 <br /> Address 15721 N. Free Road City Lodi Ca 95240 <br /> Contractor's Name NOACK PUMP CO. License# 355213 Business Phone 948-8817 <br /> 4500 E. Fremont Stockton Emergency Phone Same <br /> Contractor's Address 9 Y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No „Jit <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �! <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ + <br /> REPLACEMENT W . <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 d <br /> ❑ DISPOSAL ❑ OTHER Other Information _ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work DonePull Jet pump- d install 1-112 <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I Grout f peoiiprio grouting and a final inspection. <br /> Signed X/ ` Title: 'FRUT_CF MANAGER Date: 11 JUNE 1981 <br /> /j (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: <br /> Ph se i Grout Inspection Ph se III Final Inspection / <br /> Inspection By Date Inspection B Dat <br /> _ Fee Is Due: F-1ANNUALLY El PER UNIT El PER SITE ❑ EACH 13 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Malted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo■2009 STOCKTON,CA 95201 <br />