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Applications Will Be Processed When Submitted Properly compliewo � <br /> FOR OFFICE USE: APPLICATIO <br /> (For Non-Transferable, R bl S4 a ) pUMP&WELL <br />'k19a1 _ <br /> ENVIRONMENTAL H PERM��T Ready for Inspection <br /> f WATER QU ioR <br /> (COMPLETE IN TRIPLICATE) rein described.This application is <br /> ApplicakionisherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/�ori[1�tsh �C- uin Local Health District. <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules antr ,Ilaso��At�Town LOdI <br /> Exact Site Address 14400 E amtammt Grassland Rd. t <br /> Mike Smith `-� Phone <br /> Owner's Name Grassland Rd. City Lodi, Ca. 95240 <br /> Address 14400 E. 309031 Business Phone 727-5548 <br /> Contractor's Name GaehLicense#rina pump LockefOrd Emergency Phone <br /> Contractor's Address P•C •Box 113' g XX No <br /> .� <br /> f 1s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN El RECONDITION 11D€STRUTIONO <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER ❑ P, UMPTINSTALLAT.ION-' PUMP REPAIR❑ <br /> ' REPLACEMENT❑ Pit Privy <br /> ' !�� Sewer Lines <br /> i DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Private. Well Public Domestic Well <br /> Property Li <br /> ne�'�_ <br /> INTENDED USE <br /> `'` TYPE OF WELL <br /> © INDUSTRIAL a ❑ CASLE TOOL Dia. of Well Excavation <br /> ?I <br /> ❑DOMESTIC/PRIVATE�t •' DRILL-D _ " " <br /> —Dia.-of Well Casing <br /> Gauge of Casing <br /> C1DOMESTIC/PUBLIC E3 DRIVEN <br /> ❑ IRRIGATION y C3 GRAVELPACK <br /> Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor Goehrin Pum & Irri ation, Inc. 71 <br /> PUMP INSTALLATION: ubmer ible H.P' <br /> Type of Pump -� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Cl State Work Done b <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 /> r which this permit <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work fo <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> 1 Contractor's hiring or sub-contracting signature certifies the following:"I certify that'in,thb performance of the work forwhich this <br /> permit is is d, I s I ploy persons subject to workman's compensation laws of California." <br /> I will call a Gro t I pe n prior to grouting and a final inspection. 03�09�81 - <br /> I r Bk or. Date: <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> 1 __ <br /> FF-00i DEP7ARTMENT USE:ONLY <br /> PHASE I ' ZPhase <br /> DateApplication Accepted Additional Comments: ase 11 inal Inspection ylrout Inspection ' (� <br /> I Inspection 8y ; <br /> Date Inspection By ' Date <br /> 1 <br /> Fee IS Due: [I ANNUALLY�-�'Y❑ PER UNIT PER SITE El EACH ❑ January 1 &Recei f d By January 31 <br /> July 1 &ReceivedEMITuIy 31 <br /> BILLING REWTTANCE "$ AMOUNT DUE CHECKED <br /> iBASE -j EXPLANATION DATE DATE REMITTED AMOUNT <br /> ;c D <br /> FEE <br /> s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> s OTHER - – `• - - ..'„,r., - P <br /> OTHER ;' a <br /> lssua lee Dat Mailed Delivered dd <br /> - 4 �Receipt No. Permit No. A 95201 <br /> !, <br /> Received by Date `- 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON.CJ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES y - <br />