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Appli ns Will Be Processed When§ mitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: DEC 4 1981 APPLICATION - .. (For Non-Transferable, Revocable, Suspendable) PUMP& L SAN JO QUIN �M)MNMENTAL HEALTH PERMIT we (COMPLETE IN TRIPLICATE) HEALTH ®I.STRyCT WATER QUALITY .. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hrein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 10173 E�. Highway 12' City/Town Lodi Owner's Name Jim Wilson r;"r. t;: r' r Phone 333-1939 Address Sammi City Contractor's Name Moorman' s Water Sys.tmms? License# 267696 Business Phone. 931-3210 oQ Contractor's Address . 4243 Cherryland Ave.. Emergency Phone I f Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No TYPE OF WORK (CHECK): NEW WELL 13DEEPEN ❑ RECONDITION 13DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLAT1010 PUMP REPAIR❑ r REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy E Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE I TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION t ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC.PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL 0 Surface Seal Installed By:- PUMP INSTALLATION: Contractor r Type of Pump H,P. G z PUMP REPLACEMENT:. State Work Done emove old pump and replaced wit HP" PUMP REPAIR: ElState Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and"Procedure" I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." I Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." ' I will 11 for a Grout Inspection prior to grouting and a final inspection."F � ��_ �� Signed X Title: �f� Date: � e a f (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I o —, Application Accepted By Date �f Additional Comments" ase 11 Grout Inspection t Phase t;= n Inspection By e C Date Inspection B - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING. . REMITTANCE $BASE EXPLANATION AMOUNTDUE CHECKED DATE DATE REMITTED AMOUNT eZ3 FEE $ t LESS PRORATION PLUS i PENALTY OTHER ' OTHER � )- Received by Date Receipt No. Permit No. - Issuancb Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 {�