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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, R <br /> 5 OFFICE USE: APPLICATION <br /> ' (For Non-Transferable, Revocabl pew V ri <br /> UMP&WELL <br /> ,. ,. ENVIRONMENTAL HEAL ERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY MAR 2 7 1980 <br /> Application is hereby made to the San Joaquin Local Health Districtfora 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 re!9ANPn c4t11t)"ie"-5.Tq J0044 r�tgcal Health District. <br /> Exact Site Address 8120 E. Woodbridge Rd. AW In O <br /> Owner's Name McKenzie & Gillespie Phone <br /> Address 8120 E . Woodbridge Rd. City Acampo <br /> Contractor's Name Goehring Pump & Irricgatioaense#309031 Business Phone 727-5548 <br /> Contractor's Address P.O . BOX 113, Lockeford --_ Emergency Phone same as above Gy <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-Disposaf Field r- Cesspool/Seepage Pit Other <br /> Propi:rty Line Private Domestic Well Public Domestic Well I' <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL .Dia. of Well Excavation <br /> © DOMESTIC/PRIVATE D <br /> DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUB ❑ DRIVEN <br /> , Gauge of Casing <br /> I A ricult al ❑ GRAVEL PACK Depth of Grout Seal j <br />! ❑ CATHODIC PROTECTION 0 ROTARY <br /> Type of Grout <br />` ❑ DISPOSAL OTHER W Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor_ GOehrinq Purnp - <br /> x _ <br /> Type of Pump + : H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11State Work Done z-e p aired 15HP flood rr'.~ pump & a nOW OW 1 <br /> DESTRUCTION OF WELL ~'Well ❑iameter � -Y F <br /> Approximate Depth I <br /> Material and-P-rocedure <br /> I hereby certify that l have prepared this application and that the work will be done in-accordance with San Joaquin County <br /> �p { <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. `_-I <br /> Home owner or lice­11.nsedagent's-signatUre certifies the fbllowing:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ-arty person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permi d shall empl <br /> oy persons subject to workman's compensation laws of California.", <br /> I will c r nspection prior to grouting and;.�a final inspection. <br /> Signed X Title: Bookkeeper Date: x /80 <br /> (Draw Plot Plan on Reverse Side) <br /> - J <br /> FO PART NT USE ONLY <br /> PHASE <br /> Application Accepted By Date' <br /> Additional Comments: <br /> _ <br /> Phye.0 Grout Inspection as 11 Finalpection <br /> Inspection By Date ' -� Inspection B�✓ 'Date <br /> t4f V F <br /> Fee Is Due: ❑ ANNAaALLY - ❑ PER 0NN—; ❑,PER SITE �f❑,EACH ❑ 'Janua'ry 1 &Received By January 31, 1July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED y <br /> ( _ DATE-^ - -_+-DATE – REMITTED AMOUNT <br /> FEE 1 <br /> LESS <br /> PRORATION f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> In 3 a o <br /> Received by I 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 />