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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1761J E USE: - ltlCATION CSI (ForsRo ndable) 1. ;" f PUfvAP &WELL ,.� EN NMENTALAELto IT (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health District fora perm tttruct and/or install the work herein described.This application is made In compliance with San Joaquin Count, Ordinance A*2 ?tl,�e rules and regulations of the San Joaquin Local Health District. Exact Site Address 16400 N. Alpine Rd. .. City/Tovin ._L_odl- 4E- i J TR' -I Owner's Name Mike Stonum —_ __ - Phone _ -- - -- Address 16400 N. Alpine Rd. -- __- - .. - - City. _ Lodi- - .-• Contractor's Name Goehrl.nq Pump. & Irrigaticlense it 3090.31 _ Business Phone 727-5548 — - Contractor's Addressp•_0 BOX 113, LOckef ord I Emergency Phone ---- - Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes --. No ---- TYPE OF WORK (Cl NEW WELL MX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ FLil iNSTALLATiON [ZX PUMP REPAIR El [ REPLACEMENT DISTANCE TO NEAREST: Septic Tank -_ .. Sewer Lines __ - Pit Privy -- Sewage Disposal Field ._ _ Cesspool/Seepage Pit -_ - ._ - Other -- Property Line--- - Private Domestic Well .- - Public Domestic Well.._. - - - - - - INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— El xcavation❑ DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing - ❑ DOMESTIC/PUBLIC 11 Gauge of Casing _ - -- - ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ._ -- [3 CATHODIC PROTECTION ❑ ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: ---- PUMP INSTALLATION: Contractor- GOehrinq Pump__& I_.rrigatiori, Inc. _ — _ - Type of Pump.—. .Submergi b1e __ H.P. � — _. PUMP REPLACEMENT: ❑ State Work-Done-- PUMP Done _PUMP REPAIR: ❑ State Work Dore - - DESTRUCTION OF WELL: Well Diameter--.. Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws. and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"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 or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit I. shall employ persons subject to workman's compensation laws of California." 4 I will ca r ro Inspection prior to grouting and a final inspection. Bkpr. Date: .. 06/17/82 Signed X Title: —. —. - (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Iy � n .r4� �.t•��.._ r / Application Accepted By 14-'=x" --. - -- --.- Date Y�- Additional Comments -- - - - - - PDal II Oroul Inspection e Ilt`F' a ction Inspection By_ _ __ Date _.. . Inspection By _ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By J ily 31 — —] REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT I�,OV EEE LESS PRORATION _ -- PLUS PENALTY OTHER OTHER ----- Received by Date Receipt No Permit No.. issuanchte Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT;SERVICES 1601 111 HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1