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Applications Will PrQcFes r�� , bm'ited Properly Compiwea. weaures rv,y��• ^rr <br /> f .� PS-1 ATION Will 'Notify When Ready For <br /> FOR OFFICE USE: ii Inspection <br /> �a <br /> (For Non-Tra st rrle ocable,Suspendable) PUMP&WELL ,� J <br /> EALTH PERMIT �1 <br /> A;, ATER QUALITY <br /> (COMPLETE IN TRIPLICATE) f;^;,' <br /> Application ishereb madetotheSanJoagt�r� o l�lisattf�[�i�tr�c forapermittoconstruct and/or install the work herein described.This application Is <br /> Y L, <br /> made in compliance with San Joaquin Countyfrfa#Ic �the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 15709 N. Trethewa Rc�. lc City/Town <br /> Phone_ 3618— 6n4 <br /> Owner's Name Luis & Vir Znla Flores City Lodi <br /> Address Same as above 727-5548 <br /> Contractor's Name GOehrin <br /> Pum & Irri atlQ�ense# 309031 Business Phone <br /> Contractor's Address BOX 113 LocKeford Emergency Phone i l <br /> Xx No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> --, <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Privy <br /> Sewer Lines <br /> DISTANCE TO NEAREST. Septic Tank Cesspool Cl/Seepage Pit Other <br /> Sewage Disposal Field <br /> Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> i ❑ DRIVEN 1 Gauge of Casing <br /> 13DOMESTIC/PUBLIC Depth of Grout Seal <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> IJ CATHODIC PROTECTION [I ROTARY r Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump.'-- <br /> PUMP <br /> ump„PUMP REPLACEMENT: ❑ State Work-Done <br /> PUMP REPAIR: ❑ State WorkDor ie 100 ft, �fl <br /> Well Diameter- 8.r Approximate Depth <br /> DESTRUCTION OF WELL: . <br /> Describe Material and Procedure_filled WG 11 u t0 50 e�e.Wlf::h WaSYle <br /> It ll <br /> I hereby certify that I have prepared this application and that work lll be Healdone <br /> inct.accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local <br /> Home owner or licensed agent's signature certifies the followinb:"I certify that in the performance o <br /> . f 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 /> the work forwhich this <br /> Contractor's hiring or sub-contracting signature certifiesalie tolWwing:"I certify that in the performance of <br /> permit i s I shall employ persons subject to workman's compensation laws of California." <br /> I wi I Gr t inspection prior to grouting and a imal�spectio <br /> Tifle: <br /> j Date: � <br /> # Signed X (Draw Plot Plan on'Re erse de) <br /> FOR DEPARTMENT USE ONLY �f _ <br /> PHASE I Date 7 Z <br /> Application Accepted By <br /> Additional Comments: O <br /> hase-11 I Inspection <br /> Phase II Grout Inspectio to <br /> FInspection By <br /> Date - Inspection 13y <br /> Fee IS Due: ❑ ANNUALLY, '�❑-PER UNIT PF SITE— '❑ EACFf"'_ ❑January'1-&Received By January 3Y "El July 1.&ReceiveRdEBnylTuly 31 <br /> k 1� ` ^ ' _BILLING_.... .REMITTANCE $ - AMOUNT DUE CHECKED <br /> ' BASE EXPL"RNAT40N ' DATE DATE REMITTED AMOUNT <br /> FEE f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER. <br /> Received by Date Receipt No. <br /> permit No issue ateMailed Delivered <br /> P.O.Box 2009 STOCKTON,CA.35201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HAZELTON RYE:, <br />