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Ap tifj@,If I o s ubmitted Properly Comple e�u T i Y �liup <br /> . j <br /> F.OJ1 OFFICE USE: luil APPLICATION ` <br /> (For N ansferable, Revocable, Su able) <br /> AUG &WELL <br /> iNVIRONMENTAL HEALTH PERMITAUG 2 4 1983 <br /> (COMPLETE IN TRIPLICATSAN ,1��AO UI�We <br /> WATER QUALITY h <br /> Application is hereby made tot�Iffu Ipistrictforapermit toconstruct an p�Ni stJ RQMi1l�l�ribed.This application is <br /> made i o la with San Joaquin County o. 1862 and the rules and regulatiokJ&Wk6 N1R1GTal Health District. <br /> Exact Sttre 1/16 Mi 1e South of H 12 City/Town <br /> Owner's Name Loris Satore Phone <br /> Address 11000 E. Hyy. 12 Lodi Ca. 95240 City <br /> Contractor's Name Goehring Pump & Irri atiorIcense# 309031 Business Phone 727--5548 <br /> Contractor's Address 17754 N. Hwy. 88 LoCkeforlmergency Phone <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❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT[] (IRRIGATION PUMP) 1 <br /> DISTANCE TO NEAREST:. Septic Tank Sewer Lines Pit Privy 1 # <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE- TYPE OF WELL z <br /> ❑ INDUSTRIAL ❑ CABLE TOOL -Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED L.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 /> _ Type of Pump H.P. .. - <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done Repaired bowl S IRRIGATION WELL Q <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 Joaguin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 h1riDq or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit i s shall employ persons subject to workman's compensation laws of California." <br /> I will rou nspection prior to grouting and a final inspection. <br /> Signed X Title: Bkpr. Date. 08/11/83 <br /> ne <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1:•J.7 -- - — a � - <br /> Application Accepted By 6 j M� - Date <br /> Additional Comments: AL <br /> QQQ <br /> Phase II Grout Inspection -Ill Final Inspection _rte <br /> _ <br /> Inspection By "'-�"^'- -Date 4� Inspection By Date fv <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER- ITE- ❑i EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT PUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i <br /> I FEE �J <br /> a LESS <br /> PRORATION.. <br /> PLUS <br /> PENALTY <br /> OTHER v <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E.MAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 <br />