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Applications Will Be Processed When SubmittedProperly Completed. BeSureToSign TheApplication. FO.9 OFF, Ute-: APPLICATION (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT t (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made tothe San Joaquin LocaJ Health Districtfora permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. i Exact Site Address 13580 E . Tokay Colony Rd. City/Town Lodi Owner's Name Hugh Campbell Phone Address 13580 E. Take olony Rd. City o 1 Contractor's Name Goehring Pump License# 309031 Business Phone 727-5548 Contractor's Address p.b. Box 113 Lockeford Emergency Phone D Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ $ WELL CHLORINATION C1WELL ABANDONMENT ElOTHER 13PUMP INSTALLATION 11PUMP REPAIRXK REPLACEMENT❑ r DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information A ❑ GEOPHYSICAL Surface Seal Installed By. 0 PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: 20 State Work Done replaced old pump w 3 HP pump PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter -Approximate Depth O Describe Material and Procedure T rr I hereby certify that I have prepared this application and that the work will be done iri accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not em loy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hirin -contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit ' ed, employ persons subject to workman's compensation laws of California." I will r a nsp tion prior to grouting and a final inspection. Signed X Title: Hkpr• _ Date: 08-13-80 r (Draw Plot Plan on Reverse Side) = OR DEPARTMENT USE ONLY PHASEI Q Application Accepted ByDate Additional Comments: Phase II Grout Inspection + Phi Final pection �d Inspection By Date 43- - Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received ByJanuary 31 ❑ duly 1 &Received By duly 31 REMIT BILLING REMITTANCE $ BASE EXPLANA ION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER TT 5 JV Received by Date Receipt No Permit No. Is uance ate Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ..tee_....:, err