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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sion The Application, <br /> FOR oFF E USE: APPLICATION !K APPROV 3 W� <br /> (For Non-Transferable, Revocaf ' s��cl� <br /> �1 <br /> I PUMP&WELL <br /> ENVIRONMENTALl <br /> ERMIT(COMPLETE IN TRIPLICATE) WATER QYy;j J } <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit toconstru tand/or instailth�w ,cf�herein described.Tltisapplication is f <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and rYe�ulatip,r ` to L aquin Local Health District <br /> Exact Site Address 13455 E!: Jahant Rd. p"N S'' yam � <br /> �t <br /> Owner'11 <br /> Name Dari Groen� Phone <br /> Address 13455 E. Jahant Rd. city Acampo <br /> Contractor's Name Goehririg Pump License# 309031 Business Phone 727-5548 I <br /> Contractors Address 17754 N: H 88 4- <br /> t Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No L <br /> TYPE OF WORK (CHECK): NEWELL❑ DEEPEN 1:1RECONDITION 11DESTRUCTION❑ <br /> WELL.,'CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IN 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 d <br /> INTENDED USE � TYPE OF WELL <br /> ❑ INDfUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 0-DRILLED -"Dl y <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN 1 Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK = Depth of Grout Seal <br /> 11CATHODIC PROTECTION 13ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 1 <br /> ❑ GEOPHYSICAL '_-Surface-Seal-Installed By: . _.__ I <br /> PUMP INSTALLATION: Contractor Goehrinq ;Pum 4' <br /> Type of Pump Submersible # H.P. 7� <br /> PUMP REPLACEMENT: ❑ State Work Done t <br /> PUMP REPAIR: 13 State Work Done <br /> DESTRUCTION OF WELL: Well Diamete.r,. I Approximate Depth <br /> Describe,Mate rl;I-and-Procedure _ <br /> I hereby certify that I have preparedffiis applicalion`and'that the wid�Kwill be thine"in accoTdarice wits San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the followirl 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this f <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." *� t <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> � <br /> Sigirl Tftie; 13kpr. Date: ___(j/4/81. <br /> :I II (Draw Plot Plan on Reverse Side) <br /> I; I FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> &L <br /> Application Accepted By Date <br /> Additional Comments: <br /> I Phase ilk Grout Inspection Ph 1 I Final Inspectipins action B 1 � t�p y r Date G Inspection By Date <br /> If <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AMOUNT <br /> II <br /> LESS <br /> RRORATION II <br /> PLUS i <br /> PENALTY I� <br /> OTHER <br /> '1 <br /> ,t 'f <br /> OTHER p, <br /> Received by pate it Receipt No. Permit No.: Issu ce Dae Mailed Delivered <br /> I�APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERViCES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 96201 IJ <br />