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Ap tidissi l Y ubmitted Properly Compli I <br /> FOR OFFICE USE: lid APPUCAT1ON1111 TC <br /> - t <br /> (For N ansferable,Revocable,Su able) <br /> AUG (For <br /> HEALTH PERMITAUG 2 41983 <br /> WATER QUALITY 1 <br /> (COMPLETE IN TRIPLICATSAN JOAQUIN <br /> Application is hereby madetot�.fg14lU l Istricttore permittbConstructan r si �nenDJS'I�riealth Di trio.cation is <br /> made i` Coit is with San Joaquin County r I e No.1862 and the rules and regulatiol��� an�� ���al Health District. <br /> Exact Sitd 7��re 1216 Mile South of H y. 1.2 City/Town <br /> Owner's Name Louis Satore Phone <br /> Address 11000 E. Hyy. 12 Lodi Ca. 95240 City <br /> Contractor's Name Goehrin Pum & Irri ati ricense# 309031 Business Phone 727-554$ <br /> Contractor's Address 17754 N. H . 88 Lockefor(AmergencyPhone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION El DESTRUCTION W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT 13 (IRRIGATION PUMP) y <br /> DISTANCE To NEAREST:. Septic Tank Sewer Lines Pit Privy 'l <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <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 I-.Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN rGauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK a.Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER •Other Information <br /> ❑ GEOPHYSICAL _.._ .� --- . _ ...5urf,ace Seal Installed.By: <br /> PUMP INSTALLATION: ,Contractor " <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done J <br /> PUMP REPAIR: State Work Done RI' aired bowl S IRRIGATION WELL <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and thaCfhe work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the,San Joaguin Local Health District. I <br /> Home owner or licensed agent's signature certifies thelollowing:"I certify that in the performance of the work forwhich 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` hlrl or sub-contracting signature certilies the lot low Ing:"I certify that in the performance of the work for which this <br /> permit shall employ persons subject to workman's compensation laws of California." <br /> 1 wilt rou nspection prior to grousing arida final Inspection. <br /> Signed X Title: Bypr. _ Date: 08/11 83 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By <br /> b *` rr: _ Date (. <br /> Additional Comments: A�i"440K <br /> Phase II Grout Inspection Date III Final Inspection r <br /> ' � •- � <br /> Inspection By "�" --bate �y J Inspection By <br /> Fee Is Due:❑ ANNUALLY PER UNIT ❑-PER-SITE-- H• ❑ January i&Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> SASE EXPLANATION BILLING REWTTANCE $ AMOUNT DUE CHECKED <br /> DATE- DATE REMITTED AMOUNT <br /> i FEE <br /> a LESS <br /> PRORATION <br /> PLZ1S <br /> PENALTY <br /> OTHER <br /> ] OTHER _. <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601-E.HAZELTON AVE.,P.O.Bok 2009 STOCKTON,CA 95201 <br />