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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. " FOR OFFICE USE: APPLICATION i (For Non-Transferable, Revocable,Suspendable) PUMP&WEL-L s f ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY / 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 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 LOT #123-2345S. CURRIER DR.-5001 S . 0Fy/f6&NCHO RAMON, Owner's Name J.D. MOSHr'`' CONST. Phone _ 8R5-6921 Address' 2 E. GRANTLINE RD. -. City TRACY '�— j Contracar's Name HENNINGS BROS . License# 290813 Business Phone 545-118 Contractor's Address 2 PELANDALE MODESTO Emergency'Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF:WORK (CHECK): NEW WELL 09 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ /1.,� "j WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Vn'�l REPLACEMENT 11 - W DISTANCE TO NEAREST: Septic Tank 100" Sewer Lines Pit Privy Sewage Disposal Field 1001 Cesspool/Seepage Pit Other f Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 11 ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6" PVC ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal 501 _ ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT ❑ DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER PUMP INSTALLATION: Contractor ! 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 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. r , Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit `'7 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." i I will call for a Grout Inspection prior to grouting and a final 'nspection. 4 Signed X HENNINGS BROS. BY _ Date: 10-8-82 (Dra Plot Plan on Revers ide) FOR DEPARTMENT USE ONLY PHASE " Application Accepted l3 Date Additional Comments: Phase II Grout Inspection e I nal Inspection Inspection By 'hl/L Date 4L`'�y`A2� Inspection By Ph � •�G_ Date Z�2_ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT . ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED _ AMOUNT FEE 3 LESS PRORATION PLUS PENALTY " OTHER t OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,.CA 95201