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+ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable), <br /> PUMP&1NE1-L <br /> �Y ENVIRONMEINTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) It tC&eo WATER QUALITY Q2— t o$,0—� <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Off Peltier Rd• " See map on reverse City/Town <br /> Owner's Name para G1;Ca£i,1 Phone: <br /> Address P.Q. ox 601, City LOCU <br /> Contractor's Name Goehring _MP & lrr� �`tiMnse# 309031 Business Phone 7'27-5548 <br /> Contractor's Address P.O&BOX 113, LOCkefor[d Emergency Phone �TZ7" 548 I <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 E] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR C1 <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 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVAtE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �I <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Goehring13 & Irricrat.ion, Inc. <br /> Type of Pump submersible H.P. 3 i r <br /> PUMP REPLACEMENT: El State Work Done l <br /> PUMP REPAIR: ❑ State Work Done t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"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." <br /> Contractor's hiring�b-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit,' issued,/I hall employ persons subject to workman's compensation laws of California." <br /> I will l or a � Ins#ection prior to grouting and a final inspection. 4 <br /> Signed X <br /> 1,r./ '� / ` �/ `[!f Title: Date: <br /> (Draw Piot Plan on Reverse Side) <br /> 1 <br /> 1FOR DEPARTMENT USE ONLY ' <br /> PHASE ] �Z.� �� I <br /> Application Accepted By '' Date <br /> r <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ JuVy 1 &Received By Juiy 31 <br /> REMIT <br /> t BASE EXPLAr2TION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> J L DATE DATE REMITTED AWUNT <br /> FEE <br /> LESS <br /> PRORATION. <br /> PLUS <br /> PENALTY } � <br /> OTHER <br /> OTHER r <br /> � rY -6 [0 <br /> Received by Date Receipt No. Permit No. Iss ante Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 115131 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />