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AppliCallOnSWill tieProcessedWhenSubmitted Properly Completed. Be Sure To Sigly emp n. <br /> FOR OFFICE USE: APPLICATION -< <br /> } (For Non-Transferable, Revocable, Su d 19 _ <br /> ENVIRONMENTAL HEALTH TP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health District fora permit to Construct and/or install the, 66C,"eiif��ed.Tttisapplication is <br /> made in compliance with San Joaquin County Ordinance No, 1862 and the rules and regulation fa e, 2 i i�oaq� l ealth District- t <br /> Exact Site Address 1.2495 N. West Lane Ci /Tomvkl ` �J; r. <br /> Owner's Name: Fry Ranch , Phone <br /> Address 12495 N. West Lane City _Lodi <br /> Contractor's Name Goehring Pump & Irrl atiQAense# 309033 Business Phone 727-5548 <br /> y <br /> Contractor's Address 17754 N• Hwy. 8, LOCkefordnergency 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❑ � 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ P MP INSTALLATION C PUMP REPAIR �} <br /> REPLACEMENT❑ AGRICULTURAL) <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy X11. <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 /> ' 1 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED - _• --Dia.of Well Casing, <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal j <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 1 Other Information r <br /> ❑ GEOPHYSICAL Surface Seal Installed By: } <br /> PUMP INSTALLATION: Contractor Goehring Pump &,._I rrigation,Inc <br /> Type of Pump > Subrtie_ rsible H.P, 7;HP <br /> PUMP REPLACEMENT: © state Work Done <br /> PUMP REPAIR: ❑ State Work Done { <br /> DESTRUCTION OF WELL: Well Diameter <br /> _ Approximate Depth � <br /> Describe Material and Procedure•" r <br /> I hereby certify that I have prepared this application and that Vie 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanAe of the work for which this permit <br /> is issued, I shall not employ any person in such manner as'to become subject to3wv& _man"s compensation laws of California-" ! <br /> Contractor's hiringor sub-contracting signature certifies the � f <br /> g g _gw.ing:-'I certify that in -performance of the work forwhich chis <br /> permit is issu , i shall loy persons subject to workman's compensation'laws-of'California.` <br /> I will cal Gro ect' n prior to grouting and a final4lnspection. <br /> Signed X 1 Title Bkpr. Date: 4/20/83 <br /> (Draw Plot Plan lopiieverse Side) <br /> FOR_DEPARTMIENT-USE_O.NLY r <br /> PHASE I , t <br /> Application Accepted B �' �i <br /> p .Date <br /> Additional Comments: i <br /> Phase 11 Grout Inspection -- �� .�_ _ _..�hu a III inal In ec io <br /> JI <br /> Inspection By Date = inspection By late <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE i ❑ EACH ❑'January I &Received By January 31 ❑ July 1 &ReceWed By Juiy 31 Y <br /> BASE EXPLANATION BILLIING REMITTANCE $ <br /> REMIT <br /> DATE s DATE REMITTED AMOUNT DUE CHECKED <br /> 1 AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS ti <br /> PENALTY <br /> OTHER �. <br /> OTHER <br /> f <br /> ived by Date Receipt No.. Permit No. Issuance Oate Mailed Delivered <br /> LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 - STOCKTON,CA 95201 <br />