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—g- <br /> w _Apyl.-aatior`6 Will Be Processed When Submitted ProperlyCompleted. <br /> FOR OFFICE USE: R APPLICATION <br /> (For Non-Transferable, Revocable, Su�spendable) PUMP&WELL j <br /> ' ENVIRONMENTAL HEALTH PERMIT 14 <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> N <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 _�__8B C i � � 60�O1- _ City/Town C 1_e_M n <br /> Phone <br /> owner's Name Lodi Unified School Dist. Lodi. . N <br /> 815 W. Lockef ord St-. City ~ <br /> Address 7.2 7-5548 <br /> Contractor's Name Goehrin Pum License#309031 Business Phone <br /> Contractor's Address 17754 N. H 88 - ". Emergency Phone, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No <br /> s TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> s Property Line_ - Private Domestic Well Public Domestic Well- <br /> i <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> E ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing q <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal installed By: _ <br /> .e. ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ' <br /> PUMP REPLACEMENT:—k �" 11-State-Work Done <br /> ed um ends <br /> i PUMP REPAIR: XYState Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> _ <br /> )I 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> d is issued, I shall not'employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractors hiring or sub-contracting signature certifies the following:"l certify that in the performance of the work for which this <br /> I permit is iss d, I shall employ persons subject to workman's compensation laws of California." r <br /> f I w a G ut Inspection prior to grouting and a final inspec <br /> - `' Date: 07 26 79 <br /> Signed X Title: <br /> (Draw Plot Plan on Revers Side) <br /> FOR DEPARTM NT USE ONLY <br /> PHASE I <br /> Date <br /> FApplication Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection _ Phas 111 Final Inspection <br /> fDate Inspection By Date <br /> r Inspection By <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July i &Received By July 31 <br /> {l <br /> REMIT <br /> ` BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION REMITTED AMOUN <br /> - ¢ DATE DATE /T <br /> FEE <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> r OTHER <br /> [[ — Data Receipt No, Permit No. Issuance Date Mailed ---..fOelivered <br /> !, Received A — r T <br /> 'kR APPLICANT—RETUflN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/.SERVICES 1601 E.HA2ELTQN AVE.,P.O.Bo>t 2009 STOCKTON,CA 95201 <br />