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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR,OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 8755 Alhambra Avenue City/Town <br /> Owner's Name PERMAN BROS. Phone _— <br /> Address 350 E. Peltier Rd. , City Acampo <br /> Contractor's Name Goehring Pump License# 309031 Business Phone 727-5548 <br /> Contractor's Address P.O .BOX 113, Lockeford,Ca-Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x_ __ No _. <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <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 /> �s 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 <br /> Ty e of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done_ re laced old pump With 2HP 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 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' 'r' or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is d shal employ persons subject to workman's compensation laws of California." <br /> I will c rou nspection prior to grouting and a final inspection. <br /> Signed X Title: , Bkpr. Date: 06/26/87 _ <br /> (Draw;Plot Plan on Reverse Side) <br /> Q FOR DEPARTMENT USE ONLY (� <br /> PHASE I <br /> Application Accepted By W"moi- ,, Date <br /> Additional Comments: <br /> Phase II,G_ rout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By 'I� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ 'PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <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 <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />