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Applications Will Be Processed When Submitted roper Zp�d � Li FOR OFFICE USE: APPLICATION 1 82 A (For Non-Transterable, Revocable, Suspendable) DEC e PUMP&WELL ENVIRONMENTAL HEALTH PERMIT �, SAI ,_:..,UIN LOCAL WATER QUALITY - TH DISTRICT (COMPLETE IN TRIPLICATE) ermit to construct and/or ins ework.herein describe Application is hereby made to the San Joaquin Local Health District for a dpthe runes and regulations of t an Joaquin Local Healltth District.application is made in compliance with San Joaquin County Ordinance No: 186 City/Town Lodi Exact Site Address Rd Grassland Rd 6 2 Phone Owner's Name Clara Sobaszkiewicz City Address 0 Gr S l nd Rd 0 Contractor's Name Atha e�' Well Drillin - License#39-15-42 Business Phone 8Rd�,,,, �i V 6 Oak � Emergency Phone i Contractor's Address DO em l0 . �$ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes p❑ -- TYPE OF WORK (CHECK): NEW WELL A❑NDOIVDEEPENENT ® OTHER I710P MP INSTALLATION11 O❑❑ PUMP REPAIR❑ WELL CHLORINATION El WELL 1 REPLACEMENT® Sewer Lines – Pit Privy DISTANCE TO NEAREST: Septic Tank _ (j�1 — Cesspool/Seepage Pit 150 ft Other Sewage Disposal Field _ �.. ' _X8IPrivate Domestic Well �O Public Domestic Well Property Line INTENDED USE TYPE OF WELL 12tt to 0' 8" to 2 0 X3 CABLE TOOL pia. of Well Excavation B inch ❑ INDUSTRIAL Dia. of Weil Casing ZI DOMESTIC/PRIVATE ❑ DRILLED12 ❑ DRIVEN Gauge of Casing 11DOMESTIC/PUBLIC Depth of Grout Seal 50 f t• 11 IRRIGATION 11 RAVEL PACK 13 ROTARY Type of Grout 11 CATHODIC PROTECTION . Other Information [I DISPOSAL ❑ OTHER Steve Thi 11 GEOPHYSICAL er Surface Seal installed By: ork PUMP INSTALLATION: Contractor H.P. ~ Type of Pump "'`' ❑ State Work Done PUMP REPLACEMENT: 13PUMP REPAIR: State Work Done .. l O' to 200 Well Diameter 8 inch Approximate Depth DESTRUCTION OF WELL: fill wi th Clg t© 0 ft. then j c t Describe Material and Procedure T'Otlt U er 0 f t f while rOutin re lacement well. ( grout 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. Horne owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California.' I will c I r a Grout Ins ction rio grouting and a final inspection. Dec. 2 1982 Title: _ conth.a cbor– u� Date: - Signed X Draw-Plot Plan on Reverse Side)" FOR DEPARTMENT USE ONLY PHASE 1 d, Date ND__—6– Application lApplication Accepted By k Additional Comments! Phase Ill Final Inspection h 11 Grout Inspection � !Z 6 Inspection By Inspection By Date k Fee is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRd MIITuVy 31 BILLING REMITTANCE $ AMOUNT DUE CHECKED a BASF EXPLANATION DATE DATEREMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY tt OTHER i OTHER Received by Date Receipt-No. Permit No. Issu nce ate MaiSed Delivered ` 1501 E.HAZELTON AVE.,P.O.Boa 2009. STOCKTON,CA 9520 ir:. a APPLICANT"—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES,