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001C ni B#-pr*eo§d Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> FOR .09 ICE USE: APPLICATION ` <br /> ��1 198�(For on-Transferable, Revocable, Suspendable) READY FOR INSPECTION <br /> 13 <br /> PUMP&WELL <br /> . — ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICA� N t 011',0�JIN -`'CAL WATER QUALITY 57�(� � 1 <br /> Application is hereby madet e t " `�• <br /> pP y �"t�nU�q��l-Lc�iu�af�healthDistriciforapermittoconstructand/orinstallthework herein described.This applicaiipn Is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. a <br /> Exact Site Address12348 N. Hw-y. 99 (Freeway Mobile PkCity/Town <br /> Owner's Name Eleanor Seavey Phone _ <br /> Address 12348 N. Hwy. 99 City__ Lod' -54 <br /> Contractor's NameGoehrin Pump & I rri aL ionLicense#309031 Business Phorl 727-5 $ <br /> Contractor's Address 17754 N. Hwy. _ 88, Lkfd. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No <br /> a <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 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other_ c� <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 Done <br /> PUMP REPAIR: )�ff State Work Done repaired wiring in well <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> L. ..'Z]escribeMeteriNland.Procedure. ... <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with. an 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 workfor 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' i ' r sub-contracting signature certifies the tollowing:.'I,certify.that in the performance of-the work for which this <br /> permiji %, shall employ persons subjectto workman's compensation laws of California.I will nspettion prior to grouting and a final inspection. <br /> Signed )( Tiile:lR'1 Bk}3Y• -'Date: <br /> 05/13/81 <br /> (Draw Plot Plan on Reverse Side) <br /> -FOR DEPARTMENT USE ONLY <br /> PHASE I © ' <br /> Application Accepted By-.\ s' '"R � Date <br /> Additional Comments: lit <br /> ase II rout Inspection L111Final Inspection /Q�p <br /> Inspection By Date Inspectio y Date r `tJ2 <br /> 6 <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 /> BASE EXPLANATION BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ` <br /> 'h <br /> OTHER i q <br /> -OTHER,', <br /> - <br /> - i <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered— <br /> APPLICANT—RETURN <br /> eliveredAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />