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FOR OFFICE USE: h4' { APR?LIP�ATION Will NotifyWhenReady For <br /> 4' inspection <br /> or Non-Trariisferaplet�iSocable,Suspendable) p <br /> tf ; ; ••� PUMP&WELL <br /> 'EN�.jffGnM,ENT�4 EALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) - ' ;t ATER QUALITY <br /> Application is hereby made to the San JoagLAOL:A�'a�LHeatt-Y[Distrjc{{t--l1for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or l-Ql_ ,_)M`,14 the rules and regulations of the San Joaquin Local Health District. <br /> ,� 1 <br /> Exact Site Address 15709 N. Tretheway Rd."_"!CT City/Town <br /> Owner's Name Luis & Virginia Flores Phone 868-1604 <br /> Address Same as above City Lodi , <br /> Contractor's Name GOehring Pump & IrrigatiQlaense# 309031 Business Phone 727-5548 <br /> Contractor's Address Box 113, Lockeford Emergency Phone 1 <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 O <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 <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 r... <br /> Type of Pump. H.P. n <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work,Done C' <br /> DESTRUCTION OF WELL: Well Diameter 81r Approximate Depth 100 ft. _,9 <br /> Describe Matetial and Procedure f i 11 ed well up to 50 f t. with washed <br /> gravel, then last SO ft. with lm concrete. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for 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's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit i 's I shall employ persons subject to workman's compensation laws of California." <br /> 1 wi Gr t Inspection prior to grouting and a final inspe <br /> Signed X Title: NOV, Date: <br /> (Draw Plot Plan on Re Arse de) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By � � �—' Date �'? <br /> Additional Comments: <br /> Phase II Grout Inspectio Kase-II I Inspection <br /> Inspection By DateInspection By to <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 /> BILLING REMITTANCE $ <br /> ' BASE EXPL`ANAT'ION AMOUNT DATE DATE REMITTED DUE CHECKED <br /> AMOUNT <br /> FEE � /v ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> (,12 <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />