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Appl+cations Will Be Processed When Submittea rropen �.�••r•�•� APPLICATION FF10E USE: (For Non-Transterable, Revocable, Suspendable) DUMP&WELL ENVIRONMENTAL HEALTH PERMIT 1:5'0—2ZWATER QUA�1QUALITY (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thew ork herein described.This application Is + made in compliance with San Joaquin County Ordinance No.1862 and the ;1es a reguiati Cit /Towns of the san Joaquin Local Health District. rExact Site Address -��m7— �S W° dbri d e Rd-- T yGw;F , ' ✓'l:- Plione 369 2491 i I Owner's Name City Lodi Address — -•-�00 r1C� " Pum 0 � License# 355213 Business Phone 9$8-8817 I Contractor's Name -N_ �, Emergency Phone Same Contractor's Address --4500—E— No AA Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes VV TYPE OF WORK (CHECK): NEW W ABANDONMENT ❑DEEPEN ❑ O HERO[] 1T10p❑P IN AT O OXX PUMP REPAIR 13 ' WELL CHLORINATION ❑ WELL �✓ REPLACEMENT❑ Sewer Lines Pit Privy DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other Sewage Disposal Field public Domestic Well Property Line Private Domestic Well N TYPE OF WELL INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation r ❑ INDUSTRIAL Dia. of Well Casing ❑ DOMESTIC/PRIVATE 11 DRILLED ❑ DRIVEN Gauge of Casing ❑ DOMESTIC/PUBLIC GRAVEL PACK Depth of Grout Seal ❑ IRRIGATION Type of Grout 11 CATHODIC PROTECTION ❑ ROTARY ❑ DISPOSAL ❑ OTHER Other Information Surface Seal Installed By: ❑ GEOPHYSICAL PUMP INSTALLATION: Contractor Noack Pum CO- H� 5 Type of Pump Submersible KX State Work Done Re laced 'et um with submersible um PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: Approximate Depth Well Diameter DESTRUCTION OF WELL: Describe Material and Procedure repared this aaponstof the San Joaquin Localllbe one in Healah District. with San Joaquin County I hereby certify that i have p ordinances, state laws, and rules and regul ` Home owner or licensed agent's signature ceriflies the following:"I certify that in the performance of the work for which this permit H t ` issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 1 formance of the work forwhich this Contractor's hiring or sub-contracting signature certifies the fallowing:1 certify that in the per permit is issued, I shall empper ns subj loyect to workman's compensation laws of California." i I will ca fo G f s to outing and a final inspection. 28 MAY 1981 _ Title: SERVICE MANAGER Date: i Signed X (Draw Plot Plan on Reverse Side) r. a. FOR DEPARTMENT USE ONLY PHASE I Date I Application Accepted By Additional Comments: a 111 inal inspection �1 If Phase 11 Grout Inspection, / Date (} k Date Inspection By Inspection By ❑ ❑ EACH� ❑ January 1 8.Received By January 31 ❑ July 1 &Received By July 31 r Fee l5 Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE REMIT t BILLING REMITTANCE' AMOUNT DUE CHECKED OUNT BASE EXPLANATION DATE DATE •REMITTED AM FEE "1 LESS s PRORATION _ PLUS. PENALTY f OTHER OTHER I C>FSCj —�—$ Date Receipt No. Permit No. Issuance Date Mailed Delivered Received by - 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES.