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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication <br /> IFO�R�OFFICE USE: a APPLICATION <br /> (For Non-Transferable, Revocable, Su <br /> r s ` , 11 b LJ P&WELL <br /> ENVIRONMENTAL HEALTH R / <br /> k. WATER QUALITY i�� 1981 <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or ins al the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of <br /> tth al;r�0gge}uin�ALHealth District. <br /> Exact Site Address_12825 E. Hirne Ln. <br /> cci 1L 1 ;z <br /> I - Ln t <br /> Owner's Name Frank Marshall _ Phone <br /> Address 23710 N. ElliottjRd. , City Acam o <br /> Contractor's NameGoehrin Pum License# 30-9-D3-L Business Phone 727-5548 <br /> Contractor's Address 177 ___8$,_J,kfd-e .-C-aFmergency 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 ❑ 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 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of.Well Excavation <br /> 4, ❑DOMESTIC/PRIVATE <br /> ❑ DRILLED " " " Dia:of Well Casing <br /> kkkl ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal . <br /> e ElCATHODIC PROTECTION ❑ ROTARY - Type of Grout f <br /> ❑ DISPOSAL ❑,OTHER Other Information <br /> ❑ GEOPHYSICAL �. Stirface;Seai Installed By: <br /> PUMP INSTALLATION: z Contra orr,GOehrin � P rmn & Irri ation Inc.: <br /> Type of Pumper SUbTtte 1')Jle H.P•�` t � <br /> PUMP REPLACEMENT: r-= <br /> ❑ State Work i3Ae <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: : Well Diameteri� Approximate.Depth <br /> _ Describe Material and Procedure -Y >-- "'` `r� L <br /> I hereby certify tYAt I have prepared this application and that the.work will be done in accordance with San Joaquin County Vy <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, 1 <br /> Home owner or licensed agent's signature certifies the following:"1 certify that in the performance of the work`for which this permit <br /> is-issued-1-shall-not employ-any person in'such-manner as to become.subject to_wnr.kman's.compensatio�.laws of..,Califo.r.nia." <br /> Contractor's hiri or sub-contracting signature certifies the following:"i--certify that.in-the•iset'fdrmance of the work forwhich this <br /> —p'e'rm is is shall employ ppersons subject-to workman's compensatibn lams of'Califo�nia:" <br /> I will a To Inspection prior to grouting and a final inspection. <br /> fa1 z <br /> Signed X Title: _Bkpt + Date: �F?,_ 11 <br /> 4 (Draw Plot Plan on Reverse Side) <br /> r FOR DEPARTMENT ISE ONLY <br /> PWASE I oj�,X,®t Date <br /> Application Accepted By <br /> Additional Comments: _ '. u' u` <br /> Phase II Grout Inspection h e 111 Final Inspection ) <br /> Inspection B I�I11 n Date Inspection By Date uG <br /> [, P yam` t-l�� <br /> I <br /> 'Fee IS Due: ❑ ANNUALLY ; ❑ PER UNIT El PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE <br /> �'ys✓ <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date i Receipt No. Permit Issuance Date- -.y,..+Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />