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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ # FOR OFFICE USE: APPLICATION F (For Non-Transferable, Revocable,Suspendable) ` w ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application iS made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. >& Exact Site Address 10765 6 Wr CLOVER RD .=11_MI . WEST OF TPA Y- CiJ99V& Owner's Named RALPH HAYS S & SON INC. Phone $ Address 10765 W. CLOVER RD, city TRACY 0 Contractor's Name HENNING S BROS. License#2 90813 Business Phone Contractor's Address 3525 PELANDALE MODESTO Emergency Phone C 11 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes — _ No �TM TYPE OF WORT( (CHECK): NEW WELL DEEPEN ❑ RECONDITION 0 DESTRUCTION❑ V t WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ I f f DISTANCE TO NEAREST: Septic Tank 75 Sewer Lines Pit Privy ad Sewage Disposal Field 751 Cesspool/Seepage Pit Other Property Line . Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 IX DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6sr PVC ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL ❑ IRRIGATION GRAVEL PACK Depth of Grout Seat 50 t ❑ CATHODIC PROTECTION ROTARY Type of Grout BENTONITE O ❑ DISPOSAL, ❑ OTHER Other Information SLAB— BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER + PUMP INSTALLATION: Contractor I Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure �t 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 hiring or sub-contracting signature certifies the foilowing:"I certify that in the performance of the work for which this ` permit is issued, I shall employ persons subject to workman's compensation laws of California." " �3 I will call for a Grout Inspection prior to grouting and a final inspection. I Signed X HENNINGS BROS. DRILLING CO. _IN(ri4le: Ul'} SEC. Date: _7-80 .[ (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By „ Date Additional Comments: P s II Grout Inspection h s Final Inspection Inspection By Date_�� �. Inspection By Date o Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - PIER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT , FEE LESS { PRORATION PLUS PENALTY 1 OTHER ^ L OTHER 7 DC7 3(e �f� 6 Received by Dae Receipt No. s Permit No. Issuance Date Mailed Delivered— APPLICANT—RETURN eliveredAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 959j01,-�{,