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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F "R-_Q4rF10E USE: j APPLICATION Ready for Insbection' <br /> (For Non-Transierable, Revocable,Suspe a <br /> K II PUMP&WELL <br /> ENVIRONMENTAL HEAL F% <br /> (COMPLETE IN TRIPLICATE) � �Ot� AtE "Y B 1522/_\ <br /> Application is hereby made to the San Joaquin Local zeaoTl_XtIhVis�tric�t r onstructa Sall hewohereindbscriibe�d.�This application is <br /> made in compliance with San Joaquin Count Ordinance N . 1 <br /> p q y o 862a rules aNrtu�a ns of thean Joaquin Local Health District. <br /> Exact Site Address'--k2OOO E .11 Jahant Road cit AA' Acampo ' <br /> 3 <br /> Owner's Name Dorn Culbertson. <br /> Address 13050 E . Jahart Rd. - city Acampo <br /> Contractor's Name Goehring Pump & IrrigatigiUense# 1 Business Phone 727-5548 <br /> Contractor's Address 17754 N:l Hwy. 88, ,.LOCkGforc�mergency Phone 727-5548 y <br /> Is Certificate of Workman's Compensation l,nsurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAID 1 <br /> REPLACEMENT �, AGRICULTURAL PUMP <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 /> ` S <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> r. � ...�...._ <br /> ❑ DOMESTIC/PRIVATE ? ❑ DRILLED_��__ - Dia. of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ;i '❑ DRIVEN Gauge of Casing <br /> -IF�RIGATION ❑ GRAVEL PACK Depth of Grout Seal _. <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL i ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: li Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I--r, »-ter❑State-Work-Done • - --- -- .:___,_ _ ___ .__�_�—_„_ <br /> PUMP REPAIR: fir,-. ❑-State..Vyork-Done —DUt-21.P_W mni o-r on -Subs► 1R} <br /> DESTRUCTION OF WELL: Well DiameteF-W�"� "r”" — Approxiinafe Deptfi <br /> Describe Material and Procedure._. <br /> I hereby certify that I have prepared this applicatioij_and�that�fhe worrrli will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulationsof,the San J©aquin Local Health District. <br /> Home owner or licensed agent's signature certifiesthefollowing:"I certify that in the performance of the work for which 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." I �j <br /> Contractor's hirinq or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this j <br /> permit i shall employ persons subject to workman's compensation laws of California." <br /> I will al ro Inspection prior to grouting and a final inspection. <br /> -:signed X Title: Bk r. Dale: 05/26/83/11' y <br /> raw lot Plan on Reverse Side) <br /> �� FO DEPARTMENT USE ONLY' <br /> 4 <br /> PHASE I 1 . }� <br /> Application Accepted By V Date r <br /> Additional Comments: <br /> Pha4/106r,,it Inspection hase 111 I s clion 5 <br /> Inspection By a' Date Inspection Byd <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE. .:❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> y ' $ REMIT <br /> BILLING REMITTANCE <br /> BASE i� EXPLANATIONS AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> s <br /> FEE <br /> j <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER li <br /> OTHER <br /> i <br />-_ Received by ADB Receipt No Perm'i1 No- Issu nce ate Mailed Delivered <br />- •.. -+APPLICANT—RETURN ALL COPIES TO - ENVIRONMENTAL HEAL'TH'PERMITISERYICES.� 1601E HA2ELTON AYE.;P.O.Box 2009,. -STpCKTON,CA 95201- <br />.�« <br />