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Applications Will Be Processed When Submitted Properly Completed. Be Sµ T The Application. <br /> FOR OFFICE USE: APPLICATION � \Cv <br /> (For Non-Transferable, Revo I elaHle) WELL <br /> PUMP& <br /> ENVIRONMENTA 2 PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER TY 11 N 1 � <br /> Application is hereby made to the San Joaquin Local Health District fora perm oconstrdtand/or in t 110DOxX-{vherein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regi t ViLhzloaquin Local Health District. [}1, <br /> Exact Site Address 9602 E . H . 12 E �oty�Tbwn Lodi <br /> N <br /> Owner's Name Ha Phone <br /> Address 9601 E . Hwy. 12 City Lodi <br /> Contractor's Name Goehrin Pj�mp & Irri atiQJaense# 309031 Business Phone 727-5548 1 <br /> Contractor's Address P.O. Box 113, Lockeford Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONXI PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewdr Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well a <br /> INTENDED USE TYPE OF WELL :7_ f- <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN 1 Gauge of Casing <br /> I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 4 <br /> ❑ DISPOSAL ❑ OTHER Other Information 1 <br /> ❑ GEOPHYSICAL — —• �� ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Goehrin '"-pump & irrigation, Inc. <br /> Type of Pump ble H.P. 3 <br /> PUMP REPLACEMENT: ❑';State Work Done r ; <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter" • Approximate Depth <br /> Describe Material and.Procedure <br /> I hereby certify that 1�have prepared this applic3tion',and that the work will be done in accordance with San Joaquin County <br /> i ordinances# tate:laws,'.and rules and regulations of the San Joaquin Local Health District. <br /> 4 <br /> Homeowner or licensed agent's signature certifies the following: 'I certify that in the performance of the work for which this permit <br /> k is issued, I shall not employ any person in such manner.as,to become subject to workman's compensation laws of California." <br /> I - _ CorfErat tor's fii or sub=conNacSRg signature certifies.le following:'9 certify that in the performance of the work forwhich this <br /> permi s I shall employ pe sons-su6pj t to workman's compensation laws of California." <br /> r <br /> I wi Gr t Inspection prior to'-grouting and a final Inspecti n. <br /> Signed X - -' " `Title: = Date: <br /> (Draw Plot Plan:on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> I Application Accepted By <br /> k Additional Comments: - <br /> Phase II Grout Ins ection ' Pose Il Final In coon J // g r <br /> �fT <br /> Inspection By Date <br /> �r Inspection 1311Wate <br /> Fee 1s Duei ❑ ANNUALLY ElPER UNIT- �r PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE. DATE REMITTED AMOUNT <br /> - r <br /> FEE S � <br /> kLESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> r ' - <br /> . Received by Date Receipt No. Permit NoIssuance Data Mailed Delivered <br /> S 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICEu 1 D <br /> ^ <br />