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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> .r (For Non-Transferable, Revocable, Suspendable) r <br /> :- <br /> ENVIRONMENTAL HEALTH PERMIT ':✓ nk ` J <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ': � <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described Twiis applgifation is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin l I�h�pistr�et. H�I_��I <br /> Exact Site Address 119$$ N. Hwy. $$ City/Town it(U � ILL �_ <br /> Owner's Name Bill McGee Phone \PERM <br /> Address -_ 11988 N. Hwy. 88 City Lodi <br /> Contractor's Name GOehring Pump License# 30903.1 Business Phone ]2]-554R <br /> Contractor's Address P.O •BS?.X�ll3.Lockefor_d_C_._ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No <br /> TYPE OF WORE( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> .eZL DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ©-GRAVEL RACK--... _ Depth.of Grout Seal .- <br /> ❑ CATHODIC PROTECTION ❑: ROTARY Type of Grout <br /> ❑ DISPOSAL ❑.�OTHLR Other Inormafion <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done. replaced old .plimp With 3HP submersible <br /> 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 /> ordinances, state laws, and rules and regulations of Jhe 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." I <br /> Contractor' iring or sub-contracting signatdre certifies the following:"I certify that in the performance of the work forwhich this j <br /> Perm! ed, I shall employ persons subject to workman's compensation laws of California." <br /> I r a out Inspection prior to groutin4 and-a final inspection. <br /> Signed X Title: Bkpr. Date: 06/26/$7 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 0� i <br /> PHASE r ' <br /> Application Accepted By e 2 �7 7 ' <br /> Additional Comments: <br /> Phase II Grout Inspection h I I Final I speclion <br /> Inspection By Date Inspection By Date01 % F <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jue2- <br /> ceive By Jui 1 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> PATE PATE REMITTED AMOUNT <br /> FEE <br /> c <br /> LESS <br /> PRORATION tt7 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> r2 <br /> L <br /> Received by Date IF Receipt No. Permit No. issuance Date Mailed Delivered <br /> L.- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 / <br />