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Applications Will Be Processed When Submitted Properly Completed-Be Syc�i T The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revoea e) <br /> 4 �^ PUMP&WELL <br /> ENVIRONMENTA A� PERMIT �Q <br /> (COMPLETE IN TRIPLICATE) WATER TY 1A� 19 <br /> Application is hereby made tothe San Joaquin Local Health Districtfora per o constttlCtand!or in t II tLl(�1a�-{{�herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and reg t��tthe�'��i'3oaquin Local Health District- <br /> Exact Site Address 9601 E . HWY. 12 sw - '10ty>�Tb��w``n Lodi <br /> Owner's Name Harold Goehri nQ H Phone <br /> Address 9601 E . Hwy. 12 City Lodi (JL <br /> Contractor's Name Goehring Pump & IrrigatiQge...f# 309031 Business Phone 727-5548 1 <br /> Contractor's Address P.O. Box 113, Lockeford Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATIONXX PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r <br /> Property Line Private Domestic Well Public Domestic Well a <br /> INTENDED USE TYPE OF WELL _ f <br /> INDUSTRIAL C3 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN I Gauge of Casing r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL _- - _ - --•-. - - —• 1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Goehrincf'"Pump & Irrigation, Inc. <br /> Type of Pump bm rsible H.P. 3 <br /> PUMP REPLACEMENT: 13'-State Work Done { <br /> a. <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter" 'T Approximate Depth <br /> ' Describe Material sand Procedure <br /> I hereby certify that Pliave prepared this application",and that the work will be done in accordance with San Joaquin County <br /> ordingnccesrstafe.laws,'.and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies thelolio_W6g:,''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 /> �Cdntrat tor'sfiir"•er sub=cbntracti g signature certifies t6e-foii6wing:"I certify that in the performance of the work forwhich this <br /> permi s I Shall employ persons-subject t6 worki'Aan's compensation laws of California." <br /> I wi Gr It Inspection prior to°grouting and a final inspecti n. <br /> Signed X r j`r 'Title: ` __,_ Date: <br /> E t (Draw Plot Plan:on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> - _ I <br /> PHASE I - ! <br /> Application Accepted By Date <br /> t- Additional Comments: - <br /> Phase II Grout Ins ection A/29— P se l Final In ction / S <br /> Inspection By Date ' Inspection 8 ate ( �� <br /> i <br /> {�p� i <br /> Fee is Due: 11 ANNUALLY El PER UNIT- LJ`PER SITE ❑ EACH ❑ January 1&Received By January 31 July 1 8-Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE t DATE REMITTED AMOUNT <br /> FEE <br /> kLESS <br /> PRORATION _ <br /> PLUS <br /> � PENALTY _ <br /> I OTHER <br /> OTHER <br /> r <br /> Received by Date Receipt No Permit NovIssuance Date Mailed Delivered <br /> 165 <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES^ D 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ii <br />