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m Applications Will Be Processed When Submitted Properly Completf d,Ue�rt�f'f� ig .1 h lication. <br /> <� fFOE+7OFFICE USE: APPLICATI (3 ((5� �l1� <br /> (For Non-Transferable, Revoca I u ndable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEA PE"g 24 1979 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstrJ/R! i/oar(Jy$QLIt WF0"- ndescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and Local Health District. <br /> Exact Site Address 7662—E E . Kettlemen Ln. City/Town Lodi <br /> Owner's Name James L. Neki"tas Phone <br /> Address 7662 E . _Kettlemnen Ln. City Lodi <br /> Contractor's Name Goehring Pump & IrrigatigRnse# 309031 Business Phone 727-5548 <br /> Contractor's Address P.O. BOX 1.-13, LOckeford Emergency Phone <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 EK PUMP REPAIR❑ t� <br /> REPLACEMENT❑ m%. I <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 I TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1� <br /> ❑ DOMESTIClPUBLIG - :... _ ,_ _ _ �•_-.� -..-� .,,.__ <br /> ❑ DR11lEN r Gauge of Casing , <br /> ❑ IRRIGATION -.GRAVEL-PAGK*--, _ — �°z-Depth of Grout,Seal--- — - f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY : Type of Grout <br /> ❑ DISPOSAL ❑ OTHER . A r Other Information <br /> ❑ GEOPHYSICAL SurfaceSeal installed By: <br /> PUMP INSTALLATION: Contractor Goehin Pum & I rri ati on Inc. <br /> Type of Pump Myers" submerSlbl e H.P. 1 2 <br /> PUMP REPLACEMENT: ❑ State W_ - <br /> ork.Done:! <br /> PUMP REPAIR: ❑ State Work Doyle '^ <br /> DESTRUCTION OF WELL: Well Mmeter Approximate 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 regulations of the San Joaquin Local Health District. <br /> Home owner 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 /> ContrA4i <br /> acting signature certifies the following:"I certify that in the performance of the work for which this <br /> permi ,persons subject to workman's compensation laws of California." <br /> I will prior to grouting and a final inspection. <br /> Signed X <br /> Title: Date: r/ � <br /> (Draw'Plot Plan on Revers Side) <br /> FOR DEPA MENT USE ONLY <br /> PHASE I kL �J <br /> Application Accepted By d bate <br /> Additional Comments: <br /> Phase If 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 ❑ July i &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY yy <br />' - r <br /> OTHER <br /> l t <br /> f OTHER <br /> 7�t'--q 57 -71 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered ' <br /> 1 <br /> - . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE:,P.O.Box 2009 STOCKTON,CA 95201 <br />