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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication <br /> FOR 60110E USE: APPLICATION <br /> (For Non-Transferabld;'Revocalle,Suspendable) l PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> } (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address LOT -#125-23389 S - CURRIER DR.-150' S. OEity�%WHO RAMON WEST SID <br /> ` MOST CONST. Phone 835-6921 v <br /> Owner' Name " <br /> Address J.D.29 E. RANTLINE RD. City C <br /> f Ct. ontractor's Name HENNINCrS BROS. License# 290813 Business Phone 545-1.185 <br /> Contractor's Address 2 PELANDALE MODESTO Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ , <br /> P WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑- PUMP.REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1001 Sewer Lines Pit Privy D <br /> Sewage Disposal Field Cesspool/Seepage Pit Other. <br /> `-' <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 1 tt <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation Err PVC <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . 160 WALL <br /> ❑ IRRIGATION 2) GRAVEL PACK Depth of Grout Seal 0 <br /> ❑ CATHODIC PROTECTION M ROTARY Type of Grout CEMENT <br /> © DISPOSAL L3 OTHER Other Information .. SLAB—BY OWNER <br /> DRILLER <br /> ❑ GEOPHYSICAL Surface,Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H•P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1f <br /> ' ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Horne owner 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 is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspects <br /> 10-8^82 <br /> Signed X HENNINGS BROS. BY to: Date: <br /> (Draw Plot Ian on Reverse Side) <br /> r FOR DEPARTMENT USE ONLY <br /> f PHASE I b_I(� <br /> Application Accepted By Date <br /> i <br /> Additional Comments: <br /> Phase II Grout Inspection Pha" I/1' Inal inspection <br /> / /W'f� Inspection B �` Date <br /> Inspection 13y hY�� Date oY <br /> P _ <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 /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED AMOUNT <br /> r }� <br /> FEE <br /> LESS <br /> .PRORATION <br /> PLUS <br /> { PENALTY <br /> OTHER <br /> OTHER L ' <br /> Received by - Dat Recelpt No, Permit No. Issuance Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES - 160.1.E.HAZELTON AVE.,P.O.Box 2009 STOCKTOK CA 95201, <br />