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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION READY FOR INSPECTION NOW <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 11100 E. Liberty Rd. City/Town Galt <br /> Owner's Name Flores Dairy Phone <br /> Address 11100 E. Liberty Rd. City Galt <br /> Contractor's Name Goehring Pump License# 309031 Business Phone 72.7-5548 <br /> Contractor's Address 1_7754 N. Hwy_. 88, Locke fordEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No W <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ Poen,-31/7e l/eel 1 1, <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy b`Vl <br /> Sewage Disposal Field Cesspool/Seepage Pit Other N <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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION-' ' Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dorie"- tF' a <br /> PUMP REPAIR: State Work Done Chancre f] O nt 3HP, to 5HP _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure r` <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`bikxirict.- , <br /> Horne owner or licensed agent's signature certifies the following:"I certify that in the performance bf the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subiect-toYworkman's compensation laws of California." <br /> �4 <br /> Contractor's hiring ors -contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit i s ed, I s mploy persons subject to workman's compensation laws of California." <br /> 1 will r a Gr spe ion prior to grouting and a final inspection. <br /> Signed X Title: Bkpr.. Date: 04/20/83 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 lut In ection h se Final Inspection <br /> Inspection By a Inspection By to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ; <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -��2 <br /> Received by Date Receipl No. Permit No. fssuancelDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />