Laserfiche WebLink
AppliJsWilf4e4No64s9Wd Vhen itted Properly Completed. Besure iosign inewp canon <br /> FOR oFffcE USE: PPLICATION �e # <br /> _ ., SEP 8 Mon-Transferable, Revocable, Suspendable) UM &WELL � i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAN JOAQUIN LOCAL i <br /> (COMPLETE IN TRIPLICATE) HJ7 I � � dl R WATER QUALITY <br /> Application is hereby made totheSanJoaqulnLocaTNeal�h' ,trict fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address <br /> 3561 N. Hurd ltd. City/Town Lodi <br /> I Phone 368-7768 <br /> Robert McKee 1 <br /> Owner's Name i <br /> sameCity <br /> Address y <br /> Contractor's Name Moorman S Water SYSt9MS License# 267696 Business Phone 931-321 <br /> Contractor's Address 4243 Cherr land Ave. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13 'RECONDITION© DESTRUCTION© <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® /n <br /> REPLACEMENT❑ V <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> DGEOPHYSICAL DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> RIGATION ❑ GRAVELPACK Depth of Grout Seal <br /> ATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ISPOSAL ❑ OTHEROther Information <br /> Surface Seal Installed By: <br /> P INSTALLATION: Contractor Moorman' s Water Systems <br /> Type of Pump Submersible H.P. <br /> ` ull um and repair as necessary <br /> v� <br /> PUMP REPLACEMENT: � state Work Done <br /> k 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 /> l 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 call for a Grout Inspection prior to grouting and a final inspection. / <br /> Signed X ✓ Title: ��� � J Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 © Date ~1�� <br /> Application Accepted By <br /> Additional Comments: <br /> h s III Final Inspection <br /> P II Grout Inspection Date <br /> Inspection By <br /> Date Inspection By <br /> U <br /> Fee Is Due: 13 ANNUALLY El PER UNIT ❑ PER SITE El EACH © January 1 &Received By January 31 ❑ July 1 &ReceiveRd MIBy Tuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 <br /> Received by Date Receipt No - }� Permit N0. Iss ancOe a Mailed Delivered , <br /> - , <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERM ITISERVICES - 1601 E.HAZELTON AVE:,.P.O.Box 2009 STOCKTON,CA 95201 <br />