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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> �`�--- (For Non-Transferable, Revocable, Suspendable) ,- <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) - ALI.T_Y DC7 �r�S <br /> I <br /> _ <br /> Application is hereby made to the San Joaquin Local Health his#rict fora perm . construct and/or install the work herein described,This application i5�� <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaq ui Loca ealth District. <br /> Exact Site Address no ad a nggi .h s s+ a ma g City/Town �� <br /> J <br /> Owner's Name Glen R. Albaucrh Phone <br /> Address 3627 14 Mile Drive City Stockton <br /> Contractor's Name Goehring Pump License#309031 Business Phone 727-5548 <br /> Contractor's Address 17754 N. H 88 Emergency Phone <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 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other =, <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL- —,Dia:-of.-Well-Excavation-- <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ~ A <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information I <br /> El GEOPHYSICAL Surface Seal Installed By: iy <br /> PUMP INSTALLATION: Contractor Goehrin Pumt & Irri ation Trac. <br /> Type of Pump Vivers 5i113I1teI 5333 aH.P. 2 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done t <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth z <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 "t <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. - K� <br /> Homeowner or licensed agent's signature certifies the following-"I certify that in the performance of thework forwhich this permit I ' <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's hi}r} or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permitri f ,s`uid, I shall employ persons subject to workman's compensation laws of California." <br /> I will crya rout Inspection prior to grouting and a final inspecli�n. <br /> f% <br /> Signed X rl `, . , <br /> Title: Date: r/ <br /> (Draw Plot Plan on Reverse6cle) t <br /> DEP RTMENT USE ONLY <br /> PHASE I '' _ <br /> Application Accepted By Date € <br /> Additional Comments: { <br /> Phase 11 Grout Inspection Phase III Final Inspection ... <br /> Inspection By Date Inspection By Date <br /> e4q <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LJ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER t <br /> { <br /> OTHER <br /> Z-J-� <br /> Received by uatet Receipt No. Permit Nit. Iss ance Dafte Mailed Delivered a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />