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V�+' ApplicationsWillF Be Processed When Submitted Property Completed. B pry Tgpsi a Application. s - F17R.OFFICE USE: APPLICA�TI� �� ' 1 y } (For Non-Transferable, Revggaibll W. �bert�able) ILL__ C-01 I LOAEN R� o tUJ ? ENVIRONMENTAL HTH P M�Tj PUMP&WELL 4 (COMPLETE IN TRIPLICATE) WATER QUA ITY P' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ rinst latheQre L made in compliance with San Joaquin County Ordinance No. 1862 and the rules an ,i p! 1 erein described.This application is Exact Site Address 10030 E. Liberty Rd � ,la�i"°°�'' obi� quin Local Health District. I. ��'"`�ity/Town Galt • Owner's Name Bores Dair Phone Address + L' bests Rd City Galt Contractor's Name Goehrina Pump License# 309031 Contractor's Address P-0 . Box 113 O LCkeford Business Phone 727-5548 Emergency Phone Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes XX TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ No ON Li WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER O❑DITI PUMP INSTALLAT ODESTRUCTIN'4N PUMP REPAIR El l REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit ' Property Line Othr 4 P Y Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIALt - ; _ ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE i ❑ Dia. of Welf'Casing'' ""' +auge of Casing ' 13DOMESTIC/PUBLIC ; - �I ❑ DRIVEN ❑ IRRIGATION G ❑ GRAVEL PACK Depth of Grout Seaf ; ❑ CATHODIC PROTECTION ❑ ROTARY El -- � .� __ _ Type of Grout l ---DISPOSAL OTHER , _'_ _�❑ —.`_"GEOPHYSICAL= Other Information I " `-"'"'- "" - •-,•- ..W-.r-->-- -:�.Sur#ace_Seal_Lnstal.led-By.;��.��. _ PUMP INSTALLATION: 4 Contractor GOehririg'"PL�1Iil & Irri ation enc., t Type of Pump submersible ' H P ` 15 PUMP REPLACEMENT: ❑ Slate Work Done ` 1 PUMP REPAIR: mow_ �- ❑ State Work Done 1 DESTRUCTION OF WELL: l Well Diameter Approximate Depth i Describe Material and Procedure I hereby certify that f have prepared this application and-that the work"will be done in accordance with San Joaquin County ordinances, statelaw5, and rules and regulations of the San Joaquin Local Health District. ' ' J Home owner or licensed agent's signature certifies the following."I certify that in the performance of the work forwhich this permit I] is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California," l Contractor's hiring or'sub- nfoytracting signature certifies the following:"I certify that in the performance:df the work for which this permit is is d,'I sh persons subject to workman's compensation laws of California." u:.-- I will ca Grou r ect- n prior to grouting and a final inspection. Signed X i Title: B} r Date: 03Z24/8 (Draw Plot Plan on Reverse Side) -FOR DEPARTMENT.USE ONLY--._- PHASE ! �kL Application Accepted 0 1 Additional Comment Date Phase II Grout Inspection InspectionDate Inspection 8y By a Ill Final Inspection Q- Date }� Date '� ,ar Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 37 ❑ July-1 &Received By,iuiy 31 BASE EXPLANATION BILLING -.REMITTANCE $ REMIT 'g DATE DATE REMITTED AMOUNT DUE CHECKED FEE �Lf`� AMOUNT D LESS PRORATION PLUS j PENALTY OTHER OTHER } I' _ �° vim1 Received by - Date Receipt No. Permil No, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES I uance Daie Mailetl Delivered — 1 - 1601 E,HAZELTON AVE.,P.O.Box 2009. STOCKTON.CA 95201