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Applications W ill fie Processed When`Subrifitted Properly c;ompieieo .._ <br /> APPLICATION <br /> FOR OFFICE USE: <br /> :. <br /> Sus <br /> bl <br /> (For Non-Transferable, Revocable, pendable) <br /> / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> 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 <br /> ules <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rand regulations of the San Joaquin Local Health District. <br /> 4 ! <br /> _10 �tyw� <br /> Exact Site Address LOT 1 2 -'2 CURRIER D <br /> J.D. MOST CONST..: Phone _ �3 —6 21 <br /> Owner's NameRD City TRACY Y <br /> Address License# 29081 �_ Business Phone <br /> Contractor's Name BENNINGS BROS <br /> Contractor's Address <br /> 2 PELANDALE MODE TO Emergency Phone <br /> No 1 , <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes . <br /> TYPE OF WORK (CHECK): WELLyAB IX DEEPEN <br /> ❑❑ OTHER RECON <br /> ❑ lTlO U❑P IN <br /> AT O O❑❑ PUMP REPAIR❑ w <br /> WELL' CHLORINATION <br /> REPLACEMENT❑ Pit Privy <br /> Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank 100 Cesspool/Seepage Pit Other <br /> Sewage Disposal Field�Q� <br /> i Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation 6" PVC <br /> 11 DRILLED Dia. of Well Casing b0 WALL <br /> DOMESTIC/PRIVATE 1 Gauge of Casing 1 t <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN501 <br /> 1:1 IRRIGATION X] GRAVEL PACK Depth of Grout Seal CEMENT <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> C1 OTHER Other Information SLAB BY OWNER <br /> ❑ DISPOSALDRILLER <br /> 11 GEOPHYSICAL <br /> Surface Seal Installed By: <br /> r <br /> �. PUMP INSTALLATION: ContractorH'P' N <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done 1 <br /> # ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> t Describe Material and Procedure <br /> Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> : <br /> - <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Homs ownerny person in suchnot h manner as to become subject to workman's compensation laws of California." <br /> is issued, I or l employ ae certifies the following:sub-contracting signaturowing:"I certify that in the performance of the work forwhich this <br /> Contractor's hiring t <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 grou4PIOt <br /> al inspe t n• 10-8-82 <br /> k Signed X <br /> HENNINGS BROS. BYMe: gate: <br /> (Don Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> I Application Accepted B <br /> ! Additional Comments: Phage I Finalrinspection <br /> 4 Phase 11 Grout Inspection �� Date <br /> � Inspection By� <br /> Date - 2 inspection 8y <br /> - ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE'.' CHECKED <br /> BASE- EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> s <br /> 4 LESS <br /> f PRORATION - <br /> PLUS <br /> ( PENALTY <br /> r+ OTHER <br /> k _ <br /> OTHER <br /> Permit No Issuance Pate Mailed Delivered <br /> Received by ate. Receipt No, _ <br /> 1691'E.HAZELTON AYE.,P.O.Sox 2009 STOCKTON,CA 95291 <br /> APPLICANT ALL COPIES TO: EN_YIRONMENTALHEALTH,PERM�7,ISERYhE5 �' <br />