81-413 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To SigEflhe Application.— FOR OFFICE USE: APPLICATION - XR' rt -$-g (For Non-Transferable, Revocab sn�l 1V �' L u. &WELL }I ENVIRONMENTAL HEAL. I RMIT 1 q (COMPLETE IN TRIPLICATE) - WATER QUALITY IUB J Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install theworkhe� r�described,This application is made in compliance with San Joaquin Gounty Ordinance No.1862 and the rules and regglAtKnsiof;�tt ' ��tjJoaI o Health District, Exact Site Address �q� Z:iN. ; /Tcvgn ? � Owner's Name Goehripg Estates Phone Address P• 0. BOX 147 City Lodi Contractor's Name Goehring Pump License# 309031 Business Phone 727--5548 Contractor's Address 17754 'N. HWV. _ 88, Lkfd. Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No j 4 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRa 60 ' REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit,_ Other y , Property Line Private Domestic Well Public.bomestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED— - 4 Dia. of Well Cas(ng S ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing_ ' i ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal' I] CATHODIC PROTECTION ❑ ROTARY Type of Grout �� € `I• ❑ DISPOSAL ❑ OTHER Other Informationv f k ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor s ice. L Type of Pump .- H.P- , PUMP REPLACEMENT: ❑ State Work done �wlls� C PUMP REPAIR: EKState Worrpone — add co-Lumnx " ' { DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ( = I hereby certify that I have prepared this application and that fRie- oak will be done in accordance with San Joaquin County ordinances, state laws, and rules and+regulations;Qf-jhe San Joaquin Local Health District. �` Home owner or licensed agent's signatyre certifies the followings"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become'subject to workman's compensation laws of California." Contractor's his g or subs-conlracting signatur ce e�titi s the following::'!cet'kify 4hat in the performance of the work for which this perms I shall employ persons subject to workman's compensation laws of California." I wi Gr t II>lspection prior to grouting and a final inspection. Signed X Date: 0/4/81 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY i PHASE I -- Application Accepted By I`� , -- .. , — Date Additional Comments: iPtiase II Grout Inspection , P � s 1 I Final Mspectio Inspection ByDate Inspection By r { _ Date Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT eived By January 31 ❑ July 1 &Received By July 31 - BREMIT BILLING REMITTANCE S BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE F LESS PRORAT$ON PLUS PENALTY OTHER OTHER d a c� Received by Date Receipt No. Permit No. - Issu nce D to Mailed Delivered— APPLICANT—RETUA N eliveredAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O"Box 2009 STOCKTON,CA 95201 3� ''