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0 <br /> ` <br /> Applications Will Be Processed When 5�ubmPPLICATION pump&WELL t , <br /> ^I., vocable,Sus <br /> pendable) � <br /> ( or t � bW r' <br /> FOR QFIF USE: L PER s! <br /> IRONME U T application is 1 <br /> TERQ <br /> O G <br /> t ctandlarinstalitheworkhereindescribed.Thisapp 1 <br /> Joaquin District or he les and regulations of the San Joaquin Local Health District. <br /> (COMPLETE IN TRIPLICATE) � and the Ladi <br /> Application is hereby made to the San Joaq City/Town <br /> fiance with San Joaquin County Ord f <br /> made in comp 60.1 West Horne <br /> Lane A fSR '.g� Phone 2Q9_ 334-56.34 <br /> Exact site Address City <br /> Cit:. of Lodi 15�Q-gusiileSS Phone <br /> Owner's Name License# <br /> Address o�k��� Emergency Phone <br /> No � <br /> Contractor's Name YesJ <br /> RECONDITION❑ DESTRUCTION❑ <br /> Contractor's Address 2Q2 Compensation Insurance on File With SJLHD ❑ PUMP REPAIR❑ <br /> is Certificate of Workman's Co rpen WELL DEEPEN❑ PUMP INSTALLATION <br /> ❑ WELL ABANDONMENT ❑ OTHER y <br /> TYPE OF WORK (CHECK): <br /> WELL CHLORINATION pit PrivyOther <br /> EN <br /> REPLACEMTPOO(/Seepage Pit <br /> ❑ Sewer Lines <br /> NEAREST: Septic Tank –�� Cess <br /> DISTANCE TO Sewage Disposal Field Public Domestic WO"; <br /> --fl OF <br /> Domestic Well �r�— 611 <br /> i Property Line <br /> j TYPE OF WELL pia. of Well Excavation <br /> rte•_' <br /> l INTENDED USE ❑ CABLE TOOL Dia. Of Well Casing <br /> ❑ INDUSTRIAL ❑ DRILLED Gauge Of Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRIVEN \ <br /> Depth of Grout Seal <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Type of Grout t el <br /> ❑ IRRIGATION <br /> 1 ROTARY Other information <br /> ❑ CATHODIC PROTECTION ❑ OTHER Surface Seal Installed BT <br /> ❑ DISPOSAL <br /> n � a livable H.P. <br /> Q GEOPHYSICAL Contractor - s <br /> 1, PUMP INSTALLATION: Type Of Pump <br /> ❑ State Work Done <br /> M pump REPLACEMENT: ❑ State Work Done Approximate Depth <br /> I <br /> pUMp REPAIR: Well Diameter <br /> 4 DESTRUCTION OF WELL. Describe Material and Procedure uin County <br /> lication and that thea nock wilt <br /> He d District cordance with San 7oaq <br /> one in <br /> this app for permit <br /> I hereby certify that I have prepared ulations of the San Joaq erformanceofthewc n law Of California."this <br /> ordinances, state laws, and rules and reg I certify that inthe p ensation laws of C <br /> nature certifies the following:` <br /> i Home owner or licensed agent's sig performance of the work for which this <br /> to any person in such manner as to become;ce�efyiha woin rkman's com <br /> is issued, I shall not emp Y <br /> Contractor's hiring or submploy-contr <br /> personcting s subject to workman's comp <br /> en <br /> Taws of California." <br /> permit is issued, I shall emp Y p routing and a tin al inspection. Date. Z )5 <br /> 1 will call for a Grout ins ection prior tog EN <br /> Title: I <br /> k Plot Plan on Reverse Side) <br /> Signed X (Draw <br /> I FO DEPAR ENT USE ONLYG <br /> t Date <br /> r PHASE i <br /> Application Accepted BY g� <br /> Phase Ili Final Inspection <br /> Additional Comments: Date <br /> k hose it Grout Inspection inspection By <br /> Date 1 &Received BY July 31 <br /> Inspection By January 31 ❑ JuIY <br /> 1 ❑ January l &Received i3Y REMIT <br /> PER UNIT PER SITE ❑ EACH CHECKED <br /> Fee Is Due: ❑ ANNUALLY ❑ REMITTANCE I AMOUNT DUE AMOUNT <br /> 81LLING DATE REMITTED <br /> BASE EXPLANATION DATE <br /> I <br /> FEE <br /> LESS S <br /> PRORATION <br /> 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER//+/ <br /> IF'(� Mailed Delivered <br /> . Issuance Date <br /> Permit NoSTOCKTON,CA 95201 <br /> Date <br /> Receipt No. 1601 E.HAZELTONP•O.Box 2609 <br /> Received by IRONMENTAL HEALTH PERMITlSERYkCES <br /> ALL COPIES TO: ENV _ <br />