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_ <br /> Applications Will Be Processed When Submitted <br /> , <br /> f .# <br /> FORaOFFICE USE: (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Hence No. 1862 andDistrictfora therules and regulattiiioons oftheSan Joaquin Local Healltth Distrait..This kation Is <br /> made in compliance with San Joaquin County Ordinance City/Town Lodi. � <br /> Exact Site Address 17135 N. Trethe-war Rd. <br /> - Phone �OT1 <br /> Owner's Name GEORGE JUKE City <br /> Address Same as above 727-5548 <br /> pyo License# 309031 Business Phone <br /> Contractor's Name G�e7754nN N. H - <br /> $$, LocKeforC�mergency Phone <br /> Contractor's Address X No <br /> DESTRUCTIOND <br /> Is Cerkificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECON <br /> �P IN TAL AT ON ❑ PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> REPLACEMENTS Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cess ooI/Seepage Pit <br /> Other �! <br /> p <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation -� <br /> ❑ INDUSTRIAL - Dia. of Well Casing <br /> I DOMESTIClPRIVATE ❑ QRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> i <br /> 11 DOMESTIC/PUBLIC Depth of Grout Seal <br /> l <br /> ID IRRIGATION <br /> ❑ GRAVEL PACK <br /> C1ROTERY <br /> AR Type.of Grout - k <br /> IJ CATHODIC PROTECTION ... -:. -..... <br /> Other Information, <br /> ROT .- . ..._ _ <br /> ❑ DISPOSAL __Slurface Seal Installed,By:- <br /> [3 GEOPHYSICAL <br /> - _ Ajoaq,,nC,,nt PUMP INSTALLATION: Contractor _.__._ �•--T pe of Pump Subma State Work DonePUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: Diameter ApproxiDESTRUCTION OF WELL: V+ls&iell beMateDescribe Material and ProcedureI hereby certify that I have prepared this applicati#tand that the he San JvaquinoLo aIrk fIHalah Districtone corda <br /> ordinances, state laws, and rules and regulations o <br /> Home owner or Licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> H issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiri or sub-contracting%signature certifies the following:"I certify that the performance of the work for which this <br /> permit is ' s I shall employ persons subject to workman's compensation laws of Caltfornia." <br /> ` 1 will c l r u inspection priorrio;grouting and a final Inspectio _ 2� <br /> Title: Dale: <br /> Signed X (Draw Plot Plan on Reverse Sid ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Date 7 <br /> Application Accepted By <br /> Additional Comments: Ppa a III Fi I.Jpsp tion <br /> Phase 11 Grout Inspection ate <br /> Inspection By <br /> Date Inspection B <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivREMIT By July 31 <br /> Fee k5 Due- ❑ ANNUALLY C1 PFR UNIT CHECKED <br /> BILLING REMITTANCE $ AMOUNT DUE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> k FEE s <br /> LESS <br /> F PRORATION <br /> 1 PLUS <br /> 6666 PENALTY <br /> OTHER <br /> I OTHER <br /> qReceipt No, Permit o. <br /> Issuance ale Mail d Delivered <br /> Received by Date 1601 E.HA2ELTON AVE.,P.O.Bax 2005 STOCKTON,CA 95201 <br /> u �- <br /> aaaCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />