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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION READY FOR INSPECTION NOW (For Non-Transferable,Revocable, Suspendable) PUMP&WELL -- ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 11100 E.__Liberty Rd. City/Town Galt Owner'sName —Flores Dairy Phone Address 11100 E. Liberty Rd. _ City_ Galt Contractor's Name Goehring Puwf[t�._. License # 309031 Business Phone 727-5548 Contractors Address 17754 N. Hwy. 88, LOCkefozdEmergency Phone . Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ XX No W TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS c, \ REPLACEMENT 11 po'.,,e,, j- DISTANCE TO NEAREST: Septic Tank Sewer Lines ..._..._ Pit Privy Sewage Disposal Field _ CesspooI/Seepage Pit Other Property Line " Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED 'Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information - _r ❑ GEOPHYSICAL Surface Seal Installed By PUMP INSTALLATION: Contractor Type of Purnp H.P. PUMP REPLACEMENT: ❑ State Work L7orie "x PUMP REPAIR: it State Work Done Change from 3HP. to; 5HP DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure +� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.- Home owner or licensed agent's signature certifies the following:"I certify that in the performance bf the work for which this permit is issued, I shall riot employ any person in such manner as to become subject to'workman's compensation laws of California." Contractor's hiring or s contracling signature certifies the following:"I certify that in the performance of the work forwhich this permit i s ed. I s I mploy persons subject to workman's compensation laws of California.'' I will r a Gr spe ion prior to grouting and a final inspection. Signed X Title: Date: 04/20183 _ (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By— Date - �� I Additional Comments: _— Phase II Gr ut n ection fi se Final Inspection Inspection By a Inspection By_ leatr Fee Is Due: ❑ ANNUALLY ❑ SER UNIT ❑ P=n SITE ❑ EACH ❑ Janiary 1 d Received By January 3' ❑ .i,.y 1 &RccciveC By J.ay 37 REMIT BILLING REMITTANCE 5 BASK E%P�ANAl10N UAIE DATE REMITTED AMOUNT DUE CHECKED s - _ AMOUNT IEE LESS PRORATION PLUS -- - - PENALTY OTHER OTHER _ - � Received by Oat," Rereipl No. Pe•mit No. ssuance,Date Nladed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 �1v..