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ppucanonsWill Be ProcessedWhen Submitted Properly Comp! to ed. Be-Sure To Sign The Applicatlon. S <br /> FOR OFFICE USE: APPLICATION pY�, <br /> —'r <br /> (For Non-Transferable, Revocable,Suspendarilo- <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town Sk ek Lodi <br /> Owner's Name Dorothy H. Cali <br /> Address same Phone 369-5677 <br /> Moorman$s Water Systems City_ �Q..di <br /> Contractor's Name _ License#267696X31—�2LO <br /> Business Phone <br /> Contractor's Address 4243 Cherryland Ave. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11RECONDITION❑ No <br /> WELL CHLORINATION ❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank <br /> p Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN <br /> of Well Casing <br /> DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 11 DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed Sy: <br /> PUMP INSTALLATION: Contractor Moorman T s Water Systems <br /> Type of Pump SU rrierszble H P l <br /> PUMP REPLACEMENT: ❑ State Work Done remove existin Lim and install new 1 p <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> 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 orsub-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 wI1 for o inspection prior to grouting and a final inspection. <br /> Signed Title: �s�d �/�,' <br /> �C�u " Date: <br /> (Draw Plot Plan on Rever Side) <br /> PHASE FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase II Grout Inspection <br /> A&h <br /> 11 Final Inspectio <br /> Inspection By �. _ Date Inspection By <br /> Data <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE �/ AMOUNT <br /> �.O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. eOt No. Issuance Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESMailed ❑eRv <br /> 1$01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOTON,CA 95201 <br />