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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> V_� <br /> ='FfCE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspe leg Yi <br /> Lf WELL <br /> 17 ENVIRONMENTAL HEALTH PE I j <br /> (COMPLETE !N TRIPLICATE} /S I��d � LJ tlG W T QUALITY MAR 2 7 1980 017-3 YO-/b <br /> Appl ication is hereby made to the San Joaq In Local Health District fo a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaq,uin_County Ordinance No. 1862 and the rules and regulationghthheL ars CAp � �j, alth District. <br /> _ d <br /> Exact Sit r s bodb��, . ;:Rd=. {See map on reverse} CityR r F <br /> VA <br /> Owner's Name McKenzie & IRutledcre Phone <br /> Address 8120 E. Woodbridge Rd. City Acam o <br /> Contractor's Name Goehrin Pum . & Trri atignense# 309031 Business Phone 727-5548 i <br /> Contractor's Address P.O . BOX 113 Lockeford Emergency Phone 727-5548 1. <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes XX No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT ElOTHER 11PUMP INSTALLATION ❑ PUMP REPAIR �� F <br /> REPLACEMENT❑ F`z <br /> .# {^ t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy1 <br /> `Sewage Disposal'Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Wel! Public Domestic.Well <br /> INTENDED USE TYPE OF WELL O <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLEDr Dia. of Well Casing a j <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATtO {Agrigultlaral):1 GRAVEL PACK " Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER t Other Information <br /> © GEOPHYSICAL tSurface Seal Installed By:� <br /> PUMP INSTALLATION: Contractor <br /> r <br /> Type of Pump }' H.P. I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: XyState Work Done - 1Z" x-od it . turbine,; add new bowls- c e` <br /> DESTRUCTION OF WELL: Well Diameter rd <br /> m ! ZOIDA ' <br /> pproximate Depth <br /> Describe Material and PPocedure�� <br /> 1 4 <br /> I hereby certify that-lhave prepared this application and-that fhe work Ifl 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,f-ollowing:"I certify that in the performance of the work for which this permit <br /> is issued, I shall n t employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's r' or sub-contracting signature certiti4vthe following:"I certify that in the performance of the work forwhich this <br /> permit i i shall employ persons subject to workman's compensation laws of California. <br /> I will 1 o nspection prior to grouting and;a final inspection. <br /> f <br /> Signed X Title: Bookkeeper t Date: 03/26/80 <br /> (Draw Plot.Plan on Reverse Side) # <br /> F R PARTM T USE ONLY <br /> PHASE I t <br /> Applicaiion�Accepted By . Date <br /> �. Pn rJa, �r-7 - <br /> Additional Comments: - _- <br /> Phase If Grout f6spection Phas II final Ins ction <br /> Inspection By Date Inspection By /� at (1 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ F REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER /may s <br /> .I <br /> Received by Date I Receipt No Permit No Issuance Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />