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Applications i eTV% ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICEusE: i� APPLICATION <br /> (For N ansferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> 196VIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) �l OCAI_ WATER QUALITY <br /> Application is hereby made tot &nJ� OWN, Iffistrictfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San tv��di�y®}' ance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 9490 E ettleman Ln. City/Town Lodi <br /> Owner's Name Hilda Nmitm Handel Phone <br /> Address 9490 E. Ket-tleman L city Lodi <br /> Contractor's Name Goehring Pump License# 309031 Business Phone 727-5548 <br /> Contractor's Address P.O .12OX 113 Lock@ford Emergency Phone 727-5548 <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® <br /> REPLACEMENT❑ { <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy r <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 11DRIVEN Gauge of Casing <br /> rRRIGATION ❑ GRAVEL PACK Depth of Grout Seal .. <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information Q <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: X1 State Work Done cepa i r 1 i ne sha f t- .& a dd 201 <br /> DESTRUCTION OF WELL: Well Diameter 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 /> 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 notploy any person in such manner as to,become Object to workman's compensation laws of California." <br /> Contractor's ' In sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this i <br /> permit k hall a loy persons subject to workman's compensation Laws of California." <br /> I will al ut clion p for to grouting and a final inspection. <br /> Signed X Title: Bookkeeper Date: 05/05/80 <br /> (Draw Plot Plan on Reverse Side) <br /> OR PARTM NT USE ONLY <br /> PHASEI <br /> Application Accepted By Q l Date 6 <br /> Additional Comments: <br /> Phase tl Grout Inspection P I final fn ection <br /> Inspection By Date Inspection B.y <br /> ,l <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT i PER SITE SACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANAT BILLING REMITTANCE MOUNT DUE REMIT <br /> CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / <br /> OTHER ✓ G <br /> Received by Date Receipt No. Permit No. .. ssua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201 <br />