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._� ApplicationsWill Be Processed When Submitted Property Completed. Be Sure To Sign The Ap 'ipt cation WOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL 14EALTA PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or installthework herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. i' Exact Site Address LOT UNIT 2 SANTOS RANCH CURRIER DR Sity/Town Owner's Name JAMES MOST Phone 835-'6921 Address 29 E• GRANTLINE RD a CityTRAC Contractor's Name BENNINGS BROS s License# 290 1 3 Busines Phone —11 Contractor's Address 2 PELANDALE MOD. Emergency Phone 545--0 Is Certificate of Workman's Compensation Insurance on Fife With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ;> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 100 1 Sewer Lines Pit Privy Sewage Disposal f=ield Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation t1i 7— i DOMESTIC/PRIVATE ❑ DRILLED Ul Dia. of Well Casing 6t1 PVC E ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing WALL _ ❑ IRRIGATION IR GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY• Type of Grout CEME T ❑ DISPOSAL ❑ OTHER Other InformationSLAB.-BY 9 n� E� El GEOPHYSICAL Surface Seal Installed By: DRILLER ' PUMP INSTALLATION: Contractor � II Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done I DESTRUCTION OF WELL: Well Diameter Approximate Depth } i t Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r ordinances, state laws, and rules and reguiations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 5 r 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 following:"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," ' I will call for a Grout Inspection prior to grouting and a final lnsp ct' n. Signed X KENNINGS BROS. BY 11 -28-79 11Ie. � Date: raw Piot Plan on Reverse Sid / FOR DEPART NT USE ONLY i PHASEI Application Accepted By Date Additional Comments: - ha� II Grout Ins,�pec�ti n / Pha a NI Final Inspection Inspection By D' ate � ` o� g pection By Date L Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 _ BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED FEE AMOUNT LESS PRORATION ; PLUS PENALTY - OTHER OTHER t 0333 15 70 "7 / 7 i Received by Oate Receipt No. Permit No. Issuance Date Mailed Delivered r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 t