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Applications Will Be Processed When Submitted Profte <br /> Jp a 711 <br /> 1aI1 a"NN <br /> FOR OFF4CE USE: <br /> APPLIC r �'Vd p i�R TNS U1 <br /> (For Non-Transierable, Re, Suspendable) pllMP&WELL <br /> ENVIRONMENTALTHJHCRMIT 1981 �+ <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Ak <br /> Application is hereby madetotheSanJoaquinLocalHealthDistricttorapermitto �+c.1� lQ�r� llW�b+ hereindescribed-This application is ti <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules a j j n� I�9 I�Joaquin Local Health District. <br /> Exact Site Address 261B1 N. Graham Road city/Town s--t <br /> 5 <br /> Owner's Name J. W. MCC len.nahan Phone <br /> Address <br /> 26181 N. Graham Rdo city Galt �1 <br /> Contractor's Name GOehrin Pump & Irri atiLgMicense# 309031 Business Phone 727=554 ,( <br /> Contractor's Address 17754 N. H 88 Lkfd. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C3 OTHER ❑ PUMP INSTALLATIONXI PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> 13 INDUSTRIAL ❑ CABLE TOOL' Dia. of Well Excavation <br /> 11 DRILLED-V•- Dia.'of Well Casing` <br /> DOMESTIC/PRIVATE � <br /> DRIVEN Gauge of Casing i <br /> 13 IRRIGATION 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY , Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL �T Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor GOehriri Pum & I rri ation <br /> Type of Pump ciub H.P. <br /> PU P REPLACEMENT: ❑ State Work Done ! <br /> 1 <br /> PUM IR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter �} l <br /> Describe Material and:'P-rocedure - <br /> I hereby certify that I have prepared this applicationna d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the,Sari Joaquin-Local Health District. 6-; <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of 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 /> Contractor's hiring or su ontracting signature certifies the following:"!certify that in the performance of the work forwhich this <br /> permit is , , s ploy persons subject to workman's compensation laws of California." <br /> I will c a Gro pe n prior to grouting and a final inspection. <br /> Title. Bkpr.. Date: 07/08 8 <br /> Signed X � <br /> - (draw Plot Plan on Reverse Side) <br /> - - -7 FOR DEPARTMENT-USE ONLY <br /> ( -o� �a t <br /> PHASE l -`]11. } G�'. � � <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase If Grout Inspection se I�1 lnspectio <br /> y Inspection_By. <br /> Inspection By �.T Date- - <br /> E <br /> d By <br /> Fee Is Due: C1ANNUALLY —Q � - <br /> -PER-UNIT' 9-PER SITE- --`❑-EACH-"—r-L"❑'January-?-&Received-By-anuary-31'""' 0 July i $ReceiveREMITuIy 31 <br /> 1 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASEEXPLANATION p DATE DATE REMITTED AMOUNT <br /> FEE � <br /> LESS i <br /> r PRORAT$ON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> fi <br /> OTHER <br /> Received by <br /> Date Receipt No Permit No. Is5iJance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES '1115131 E.HAZELTON AVE.,P.O-Box 2009 - STOCKTON,CA 95201 <br />