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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F011-10 t FILE USE: APPLICATION jry C� q <br /> - (For Non-Transferable, Revocable, Suspendabl + d Iia <br /> ENVIRONMENTAL HEALTH PERM r� <br /> (COMPLETE IN TRIPLICATE) _ _WATER QUALITY RAR 27 1980 <br /> Applicat'ionishereby madetotheSanJoaquin Local Health,Districtforapermittoconstruct and!onnst Id work herein described.This applicatiionis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of thy, rr'1t3�t�i bWgr-1 tMl District. - <br /> Exact Site Nddress East Jack Tone Rd.- ( see map on. reve w LTH mac j I H <br /> Owner's Name Goehring Bros. Dairy Phone <br /> Address 15620 N. Jack Tone f Rd. City Lodi <br /> Contractor's Name nGoehrincf PumpLicense#309031 Business Phone 727-5548 C <br /> Contractor's Address P.O . BOX 113 , Lockeford Emergency Phone 727=5548 <br /> d <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❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® r <br /> REPLACEMENT❑ Ir <br /> DISTANCE TO NEAREST: Septic Tari0 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspooi/Seepage Pit Other r <br /> i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USES-TYPE-OF WELL <br /> ❑ INDUSTRIAL TOOL -' a- —Dia.-of-Wel Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ `❑ DRIVEN Gauge of Casing <br /> IRRIGATIO Agricultural GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump .H.P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: DCState Work bone 1 15HP irr, ,_trb' j4g,fprrepairs; add new bow1E� <br /> DESTRUCTION OF WELL: Well Diameter Approximatb Depth <br /> Describe Material and Procedure <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 regulationa.of the San Joaquin Local Health District. ' <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance oftti work for which this permit \e <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." CC <br /> Contracto 's or sub-contracting signature certifies the following:"I certify that in_tho-p&foimance of the work forwhich this <br /> permit ' I shall employ persons subjtrct to workman's cdmpensation laws of California."s,i TSI <br /> Will Cal ro Inspection prior to grouting ancf a final inspection.-.=• ^ <br /> ' Signed X — ---�.—��= Title: <br /> Bookkeeper Date: 03/26/80 <br /> M (Draw Plot Plan on Reverse Side) <br /> F DEPART ENT USE ONLY <br /> PHASE rt.. <br /> Application Accepted By Dat <br /> Additional Comments: , <br /> Phaee ll Grout Inspections Ph Final Iry4ection <br /> Inspection By Date Inspection By ate �� <br /> f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 40 January 1 &Received By January 31' ❑ Juiy 1 &Received By July 31 <br /> I . , REMIT <br /> I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTER AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS <br /> i PENALTY <br /> I OTHER <br /> 1 OTHER FF <br /> r <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered ._ - <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,,CA 95201 <br />