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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign FOR' FFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL f -�' ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Applicationis N TRIreby LICATmade 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. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact--site Address 10 #124-23405U IE -300 SOUTatyk,EwIRAI�C�O RA��W�+s�T Sin i` J D. MOST CONST. Phone, S -6 21 Owner's Name TRACY t. Add ass 29 E. GRANTL INE RD. 2 081 City 1F -118 � Contractor's Name IHENNINGS BROS . License# n 3 Business Phone Contractor's Address 2 5 PELANDALE S MODESTO Emergency Phone Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes R No j TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION O DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1001 Seer Lines Pit Privy Sewage Disposal Field 10011 Cesspool/Seepage Pit Other F Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 11 rr ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC ❑ .DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal 501 ❑ CATHODIC PROTECTION M ROTARY Type of Grout CEMENT EIDISPOSAL ❑ OTHER Other Information SLAB--BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER PUMP INSTALLATION: Contractor Type of Pump H.P, f PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: © State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure r 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 forwhich 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 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 insp ction. HENNINGS BROS. BY Title: Date: 10`"5-82 Signed X ' (Draw lot Plan on Reverse Sid C FOR DEPARTMENT USE ONLY PHASE Itl� Application Accepted B Date Additional Comments: i Phase 11 Grout Inspection P s 11 F' Inspection Inspection By Date Inspection By Date /a �y { Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 REM$T BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT �FEEESS PRORATION PLUS PENALTY OTHER - - -------------- OTHER Received by Date C J Receipt NC3o. P�Eerrmmiit No.IJ Issuance Date Mailed Delivered tai- 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201