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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION Ready for inspection <br /> r (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a 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 11555 E . MENNMf Brandt Rd. City/Town <br /> Owner's Name Donald Redf earn Phone ��AA <br /> Address 11555 E . Brandt Rd. City Lockeford W <br /> Contractor's Name Goehring Pump & IrrigatioMcense# 309031 Business Phone 727-5548 . <br /> 17754 N. H 88, Lkdf. Emergency I <br /> Contractor's Address �� gency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Xx No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11 RECONDITION❑ DESTRUCTION❑ —z r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM 6' <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 i <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation E <br /> ❑ DOMESTIC/PRIVATE 0-DRILLED - _ '� yDia'of Well Casing y rt <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 —Surtace.Seal Installed By.:,.___._...--- __ Vt <br /> PUMP INSTALLATION: Contractor /(1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done (� <br /> PUMP REPAIR: ❑ State Work Done —5.Plied_s-ubi-Ler-si.b-Le—w-i-r2-1-n—the--we1 7 t <br /> DESTRUCTION OF WELL: Well Diameter Approxi mateDepth <br /> Describe Material and Procedure =` <br /> i hereby certify that I have prepared this application-and that1he work will be done in accordance witfi San Joaquin County <br /> ordinances, state-laws, and rules and regulations of the San Joaquin Local Health District.—— <br /> Homeowner <br /> istrict.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 hir' g or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> 1 wil c f Gro Inspection prior to grouting and a final Inspection. <br /> Signed X Title: Bkpr. Date: 04/25/83 <br /> (Draw Plot Plan on Reverse Side) <br /> — FO DEPARTMENT USE ONLY }-- - T- - <br /> PHASEI <br /> Application Accepted By Date L 2 <br /> Additional Comments: <br /> Phase 11 Grout Inspection h s 111 Final Inspection <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 &Received By July 31 <br /> BREMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REM€TTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE . y S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I uance ate !Nailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo■2004 STOCKTON,CA 95201 <br /> g,i <br />