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Applications Will Be Processed When Submitted Properly Completed. Be Sure TA Sign-the13A <br /> tion. <br /> FOR OFFICE USE: APPLICATION <br /> {For Non-Transferable, Revocable <br /> P W �ENVIRONMENTAL HEALT RMITL 1981 MP&WELL <br /> {COMPLETE IN TRIPLICATE} WATER QUALITY .J <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal(ttlgydc lh <rttfiescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regul i lottflr` ar) �Wy t-�° <br /> aY� eal Health District. i <br /> Exact Site Address 15620 Ns Jack.ToX1e Rd aYJ <br /> Owner's Name GOe_hr nJ BYO9, Dai-r-y Phone 'I <br /> Address 15620 N. Jack .Tone Rd. city Lodi <br /> Contractor's Name Goehring Pump & _IrrigatiOYLicense# 309031 Business Phone 727-5548 0�} <br /> Contractor's Address17754 N. HWy. 8$ ,.. Lkfd. Emergency Phone 1 <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 INSTALLATION ❑ PUMP REPAIR M <br /> REPLACEMENT❑ - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> ewage Disposal Field Cesspool/Seepage Pit Other <br /> Pr erty LinePrivate Domestic Well— Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL '.Tbia. of Well Excavation <br /> OMESTIC/PRIVATE R _❑'DRILLED "`'Dia.of Well CasirSg <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN ,Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK -Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY i�Type of Grout <br /> ❑ DISPOSAL <br /> .; �� fork ❑ OT11'ER Other Information <br /> ❑ GEOPHYSICAL -=_ Surface Seal Installed B <br /> ___ _. w y. <br /> UMP INSTALLATION: Contractor + <br /> Type of Pump H.P. <br /> PUMP MENT: ❑ State Work Done <br /> PUMP REPAIR: TyState Work Done Rep <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this applicatioh"anc}thAt the work will be done4il accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin,Local Health District. <br /> Home owner or Licensed agela('s!sig ure oevtifie!�the_following:''I certify that in the performance of the work forwhich 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." 7 <br /> Contractor's firing or contracting signature oertlfies the following:"JI certify that in the performance of the work for which this <br /> permit i u d, I s I m 3 0y pl rson�subjecF:to_-vorkman's compensation laws of California," <br /> .v. .e ' t I Y <br /> I will I a Gr pe on prior to grouting and a final inspection. <br /> Signed X Title: Bk r. <br /> mss,' _'C-;'(DraW—PJot Plan on Reverse Side) Date: 07 0$ $1 .� <br /> —= FOR DEPARTMSNT.`USE O.NLY... ., <br /> PHASE I • <br /> Application AcceptedByDate <br /> Additional Comments: <br /> Phase 11 Grout Inspection I ase 11 n Inspection <br /> Inspection By NQ — Date ' Inspection By a Gv <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH '❑,,'January 1 &Received By January 31 ❑ July 1 &Received By July 31 ` <br /> ! <br /> BASE """"'EXPL"ANATION"" "-"'-w-BILLiNG,,,..�-.^ REMITTANCE. REMIT <br /> . . _ __.w$ '4 <br /> --AMOUNT DUE CHECKED <br /> DATE DATE REMfTTED AMOUNT <br /> FEE 1557^ <br /> WP <br /> LESS <br /> PRORATION - <br /> PLUS ; <br /> PENALTY _ - <br /> i <br /> OTHER <br /> - f <br /> OTHER <br /> ai <br /> 34 1!` 7 Id_ <br /> Received by Date Receipt No. Permit No. Issuance iDate ; Mailed .Delivered - <br /> k <br /> a,. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMINSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 '"STOCKTON,CA 95201 _� <br />