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Applications Will Be Processed When Submitted Properly —...I f APPLICATION U/J FOR OFFICE USE: (For Non-Transferable, Revocable, Suspendable) pUMp&WELL ENVIRONMENTAL HEALTH PERMIT ' WATER QUALITY application is (COMPLETE IN TRIPLICATE) Application is hereby made`to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This app r i made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations ity/T he San Joaquin Local Health District. ` 99 Exact Site Address__11332 N. phone Owner's Name Wa side , artments City 1 Address 1133 N. x 99' 3090 Business Phone�27�`�`z4 Contractor's Name Goehrting Pum & Trr_gatiolClcense#�— Phone Contractor's Address P•0 ' BOX 113' --Lockeford Emergency XX No �— I Is Certificate of Workman's Compensation Insurance on File With SRECO Yes TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION IJ DESTRUCTIO l WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR❑ REPLACEMENT❑ Sewer Lines Pit Privy f DISTANCE To NEAREST: Septic Tank _ Other Sewage Disposal Field_ Cessp � - - oo_ l/Seepage Pit Public Domestic Well LL Property Line TYPE OF WELL Private Domestic Well k' ` INTENDED USE Dia. of Well Excavation ❑ INDUSTRIAL ❑ CABLE TOOL ❑ DRILLED Dia. of Well Casing l ❑ DOMESTIC/PRIVATE Gauge of Casing❑ DRIVEN ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal q I ❑ IRRIGATION ❑ ROTARY Type of Grout ❑ CATHODIC PROTECTION ❑ OTHER Other Information 7 ❑ DISPOSAL Surface Seal Installed By: t ❑ GEOPHYSICAL t Contractor H.P. PUMP INSTALLATION: Type of Pump [3State Work Done PUMP REPLACEMENT: 11 State Work Don PUMP REP Approximate Depth Well Diameter 1m._�r�itL4V � 1 STRUCTION OF WELL: u1 1 out EX��I�j—et--� —ft-- Describe Material and Procedure ucasing 3 ft. below round- fill well w concrete to foundation-cut Of t� hereby c rtrify0 that have prepared this applicatio thand that e San Jothe work aquin LacalllHealbe tlh District accordance with San Joaquin County s and regulations Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this perms ordinances, state taws, and rule is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation taws of California ." [ ctontracting signature certifies the following:"I certify that in the Contractor's hiring ors performance of the work forwhich this l i d, I mploy persons subject to workman's compensation laws of California." permit e I will e G sp ion prior to grouting and a final inspection. Bkpr.� Date: 17 4 81 F Title: —� .I Signed X (Draw Plot Plan on Reverse Side) " FOR DEPARTMENT USE ONLY Date 5 PHASE I Q A-1/m r Application Accepted By Additional Comments:. Phas 1 I Final Inspection P ase II Grout Inspection � , q V I ]_ inspection B —'Date t pate—�-�,J(1 V I Inspection By ❑ January 1 &Received By January 31 ❑ July l &Received By July 31 REMIT Fee Is Due: ❑ ANNUALLY [1 PER UNIT ❑ PER SITE EACH REMITTANCE $ AMOUNT DUE CHECKED ' BILLING ED AMOUNTEMITT �. BASE EXPLANATION DATE DATE R 1 ITT l rp-�f FEE `--� f LESS PRORATION PLUS PENALTY 1. OTHER OTHER C l M-1113. Permit Delivered t Receipt No. Permit No. issuance DaSe.. 1 � Received by Date 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 452e1 APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICE -