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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR�G'FFICE USE: T- APPLICATION <br /> (For Non-Transferable, Revocable,Suspendabl 7° I 'VU <br /> z <br /> ENVIRONMENTAL HEALTH PERM1 LLI <br /> �C}G�(�iwDo WAT UALITY . t 15 1981 <br /> (COMPLETE IN TRIPLICATE) // / <br /> Application is hereby made a San Joaquin Local Health Dlstrfct for ermit oo co�nd/or install the work herein described.This application is <br /> made in compliance wit an Joaquin County Ordinance No. 1862 and the rules and regulations of tlg ft�n Jp W Locai Hea1tF}District. <br /> _ a , <br /> Exact Site Address /�C/�1`Yl - �')C>�ll . K�� '4 0 F t ` ity/Town <br /> Owner's Name Steve Graffigna _ Phone <br /> Address 9101 E. Acampo Road city Acampo., Ca <br /> Contractor's Name Goehring Pump License#309031 Business Phone 209) 727-554 <br /> Contractor's Address P.0 . BOX 113, Lockeford Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No �� <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN 11 RECONDITION 13DESTRUCTION❑ <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 <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 Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP•INSTALLATION: Contractor Goehring Pump & Irrigation,ori Inc. <br /> Type of Pump submersible H.P. 3 <br /> PUMP REQLAGEMENT: ElState Work Done <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 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I s employ personssubjectto workman's compensation laws of California." <br /> I will r a Ins ction prior to-grouting and a final inspection. <br /> Signed X Title: Bkpr.. Date: 01/14/81 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> � f <br /> PHASE I <br /> Application Accepted By C) Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phpgflll Final spection <br /> Inspection ByDate Inspection By ✓� ate '6r <br /> Fee IS Due: ❑ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ y Januar r <br /> J." <br /> 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I uance 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 />