Laserfiche WebLink
Applications trtrIii we rrocesseR wrien auominea rropeny s-ampieseo. we cure so argn I ne fapprlcaalon. <br /> ,E USE: L <br /> CATI®N /'`'� <br /> (For P r f A off--- b' J <br /> EN NMEt TALE L IT <br /> SCAAWD <br /> t <br /> (COMPLETE IN TRIPLICATE) u da <br /> plication is hereby made to the San Joaquin Local Health District fora per o�tructand/or install the work herein described.This application is <br /> Je':n compliance with San Joaquin County ordinance NA##2 <br /> ttLq rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 16400 N. Alpine Ria -AF .VR-J;N _A1 City./Town Lodi _ <br /> ICT <br /> Owner's Name Mike Stonum Phone _ <br /> Address 16400 N. Alpine Rd. _ _ City Lodi <br /> Contractor's Name Goehring Pump & IrrigatiQ-gense# 309031 Business Phone 727-5548 4� <br /> Contractor's Address .0 .BOX 113, Lockef ord, Ca-Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes— — No <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9X PUMP REPAIR❑ E2 <br /> RE=PLACEMENT❑ a <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <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 /> © 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: 1 <br /> PUMP INSTALLATION: Contractor GOEehrina Pump & Irrigation, Inc. <br /> -type ofPump Subbersi_ble H.P. 1 - <br /> PUMP REPLACEMENT, '❑ State Work.Done._� <br /> PUMP REPAIR: © State Work Done <br /> �TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure "C <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 Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich 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 /> Contra"Oef <br /> or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit hall employ persons subject to workman's compensation taws of California.' <br /> I will Inspection prior to grouting and a final Inspection. <br /> Signed XTitle: <br /> skpr. Date: 06/17/82 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By no, Date ._.4 f" - <br /> Additional Comments: <br /> P II Grout Inspection a III`F' e ction <br /> 10 Z <br /> Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received ByY1,31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE BATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. kssuancd Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES iso1 E.HAZELTON.AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />