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t ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1FC:._ -FICCE USE:• APPLICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein 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_A4J2 S. Hutch i n 5 St reot ._ City/Town Lod Owner's Name City of Lodi Phone 20 34-5634 Address City Lod I Contractor's Name man Joaau_i n PUfpp License# Business Phone 20 69-8471 Contractor's Address P _0- Bax-2.0 1 , Lod ii , CA — Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER LY! PUMP INSTALLATION ❑ PUMP REPAIR C1 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank - - Sewer Lines --- Pit Privy --- Sewage Disposal Field --- Cesspool/Seepage Pit --- Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL )Q CABLE TOOL Dia, of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing of this riata) . DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done l6W5A My1JW0P1WU Weli Diameter Approximate Depth MODIFICATION OF WELL: Describe Material and Procedure r round. It is to be—r-aised to the ground surface. 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. Horne 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." 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." c 1 will call for a Grout Inspection prior to grouting and a final inspection. Signed X Mark Linds Title: Assistant Civil Engineer Date: 3/18/8) < (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I - Application Accepted By Date Additional Comments: Phase II Grout Inspection �Pha III Final inspection ` Inspection By Date -Inspection By D e / Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 1 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT 5 BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER /41 . ..Z7=/ � Ufa s�_/�•� , Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered , APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .