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Ications Will Be Processe n Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: AUG 16109$2 APPLICATION <br /> y (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ' *� ° 0vi �- IRONMENTAL HEALTH PERMIT <br /> "EAL' 1i ®3S �� WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health 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 4614 E. Armstrorg Rd. City/Town Lodi <br /> Owner's Name Mr. G CastaP�,�no Phone <br /> Address 461.4 E ArmlCity <br /> Contractor's Name Moorman' s Water Systems License# 267696 Business Phone 431-3210 0 1 <br /> Contractor's Address 2120 ilii I Cox Rd. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN CJ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 /> ❑ IIJDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ZrRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - <br /> Q DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Deepen existing Well Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman'a Water Systems <br /> Type of Pump S'�� li H.P. 7 <br /> PUMP REPLACEMENT: ❑ State Work Done pul 1 pump,deepen wel 1 and rrsinstai 71 pUM +� <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 will cell for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: j"_ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By © Date <br /> �� � <br /> Additional Comments: <br /> Phas II Grout Inspection as I Fi al Inspection /d l <br /> Inspection By 16, Date Inspection By Date /- I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> Q�� 0 <br /> FEE �/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. 1 uance Eyate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON_AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />