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Applications Will'Be Processed When Submitted Properly Completed. Be Sure To ST�ejp i at . <br /> FOR OFFICE USE: APPLICATION <br /> - (for Non-Transferable, I Revocable, Suspenda �J <br /> ENVIRONMENTAL HEALTH PERM ,� �u� �,O &WELL <br /> (COMPLETE IN TRIPLICAtWe-`Sz <br /> ) Z3 � � �ljt�i�ie j �VA<ITY i I`a�'. +� r <br /> ,4 <br /> Application is hereby made nJoaquin Local Health Dist ct for a permit to construct and!or install t� irk kte're�r►� t i Tis application is <br /> made in compliance with an Joaquin County Ordinance No. 1862 and the rules and regulations of the �i d u;,rfAocal Health District. <br /> Exact Site Addre - See map Ori reverse City/Town <br /> Owner's Name Dan Groen Phone C <br /> Address P.O. Box. 601, City Lodi C� <br /> Contractor's Name ;-Gbehrina Pump & IrrigatiVildense# 309031 Business Phone 727-5548 <br /> Contractor's Address P?:�.BOX 113, LOCkeford Emergency Phone 727-5548 <br /> Is Certificate of Workman's Compensation In rance on File With SJLHD? Yes XX No <br /> TYPE OF WiORK4.CH_ECK):._ NEW WEL DEEP_EN_❑ . RECONDITION❑ DESTRUCTION El <br /> WELL CHLORINATION--0 �,.OER <br /> WELL ABANDONMENT`0,_' TH _13. PUMP INSTALLATIONMC PUMP REPAIR❑ <br /> REPLACEMENT❑ `� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL [--],'CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN- Gauge of Casing �} <br /> 11 IRRIGATION ❑ GRAVEL PACK. Depth of Grout Seal C+1� <br /> 13CATHODIC PROTECTION ❑ ROT.'RY.. Type of Grout er; <br /> ❑ DISPOSAL: E1,.OTHER' Other Information' <br /> ❑ GEOPHYSICAL = -- - —_ ` ` w +a „ Surface Seal Installed By: <br /> PUMP INSTALLATION * Contr'acfar,-+(Fgehrina Pump &_Irrigation, Inc. <br /> .Type of Pump 3 <br /> • I-I.P.� , <br /> { r � I <br /> PUMP REPLACEMENT:- <br /> PUMP <br /> EPLACEMENT:PUMP REPAIR.- ❑ State Work Done <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 /> iI <br /> ordinances, states laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i <br /> is issued, I ;hall ndt.employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring • b-_contracting signature certifies the following:"I certify that in-the performance of the work forw_hick this <br /> permi sed" II employ persons subject to workman's compensatoli laws of California." <br /> t I wi oT-a Ctioh priorto grouting~and a final inspectioli =-- - w --- -- w - 1 <br /> Signed X Title: Date: j <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: / A <br /> Phase H Grout InspectionR fl Final pection� �O <br /> Inspection By Date!' inspection By / Date <br /> Fee IS Due:;.❑ ANNUALLY ❑ PER UNIT .t FER SfTE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 4# e <br /> ' n,tiilx i`.'+ts'•,` x <br /> }'..:.{t'-E BILLING REMITTANCE S REMIT <br /> BASE'' '`EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ( AMOUNT <br /> FEE <br /> LESS z <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance qaIF Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL NEALTR PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Bax 2009 STOCKTON,CA 95201 <br />