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T Applications Will Be Processed When Submitted Properly Completed. Be Sure.12 <br /> x Ir7, L 9 <br /> JOAt OFFICE USE: <br /> APPLICATION ��. <br /> 4 _ (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT JAN 15 91& ` <br /> WATER QUALITY . ,J P 23 —!�Q <br /> (COMPLETE IN TRIPLICATE)..'�Z.`FLS-t) 'XiW � � <br /> p e. @ �,',a,R 9 <br /> Application is hereby made to the San Joaquin Local Heal h Districtfora permit to construct and/or install tGA Nk,6gi,8,'4es�l'ibedr At-application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the SaH&A4JTA-LoUi%U1LPa,tjistrict. <br /> Exact Site Address H - e 88 Just South of MOkelumne RivercityiTown <br /> Owner's Name TEICHERT CONSTRUCTION Phone <br /> Address c o Tom Perry, P.O .Box 15002 Sacto . 95813 city <br /> Contractor's Name Goehririg Pump License# 3090.31 Business Phon 209 7 7-554 <br /> % <br /> Contractor's Address P.O. BOX 3 3 3,LOC]�e —— Emergency Phone <br /> i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD?. Yes XX No <br /> TYPE OF WORT( (CHECK): 1NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i <br /> WELL CHLORINATION,❑ WELL ABANDONMENT 13OTHER 13PUMP INSTALLATION)U PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: '-.$e Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> � Property.Line Private Domestic Well Public Domestic Well ,f <br /> INTENDt_D-USE TYPE OF WELL <br /> i <br /> 11 INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> Gauge of Casing <br /> 11DOMEST.IC/PUBLIC ` ❑ DRIVEN, r <br /> ❑ IRRIGATION :` : ' GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ° ❑ ROTARY .:� Type of Grout <br /> I 11 DISPOSAL C3OTHE�i"'� <br /> Other Information <br /> 13 GEOPHYSICAL , `` ••-._4 W Surface Seal Installed By: j <br /> ,.: <br /> PUMP INSTALLATION: Contractor CSO hZ lt1 Pum =_ .IrrigationInc. <br /> v�—. z submerse ble .� T. H.P. 3 4 <br /> I'f.Type of Pump— <br /> PUMP <br /> PUMP REPLACEMENT: ❑-State tiNork Done <br /> �. <br /> PUMP REPAIR: ❑ State Work Done, <br /> r <br /> DESTRUCTION OF WELL: Well Diamefir Approximate Depth_ <br /> Describe Material and,Procedure <br /> I hereby-cer-tify.,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. CX/J <br /> Home owner or licensed agent's signature ertifies 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 theAollowing:"I certify that in the performance of the work forwhich this <br /> permi 's d, I shall employ persons subject to workman's'compensatian laws of California.' <br /> I wa I a out Inspection prior to grouting and a final inspection.. <br /> Signed X Title: Bk r.. Date: 1114281 <br /> (Draw Plot Plan on Reverse Side)., <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> M Phase II Grout Inspection RPh se III Final RspectionF <br /> Inspection By Date _ Inspection By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEB�y July 31 <br /> 1 - - BILLING REMITTANCE AMOUNT DUE CHECKED <br /> 5 - BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> bol X32- <br /> Received by Date Receipt No. Permit No. Is uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH ITlSERYICES• X1601 E.HAZ LFON AVE.;P.O.Box 2009 r STOCKTON,CA 9520 - <br />