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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign 1neAppucauun. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUAP&WEIL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Applirationishereby made tothe San Joaquin Local Health District for apermit toconstruct and/or install the work herein described.This applicationls J <br /> made in compliance with San Joaquin Count Ordinance No. 1$62 and the rules and regulations of the San Joaquin <br /> RAMONcaI WEST District. <br /> ExactlSlte AddressLOT #1 z2-2 �6 S . CURRIER DR.- 00' S . O1Fit�Q <br /> iPhone <br /> Owner's Name _ J XT. MOST CONST. <br /> IEE? 11c� <br /> City— "I 13111111JIJ. <br /> Address License#J 2 081 Business Phone 54 5-1185 <br /> Contractor's Name HENNINGS BROS. Emergency Phone <br /> Cont'ractor's Address 3 52 <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLWD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL ❑❑ OTH RRECO❑ ITIO PUN <br /> INSDTAL ES AT ONO❑❑ PUMP REPAIR <br /> WELL CHLORINATION 11 WELL ABANDONMENT <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1008 Sewer Lines Pit Privy <br /> Sewage Disposal Field 1001 Cesspool/Seepage Pit Other <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 6" PVC <br /> M DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing .. <br /> El DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t 60 WALL <br /> o <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal CEMENT <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> © DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ` PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done §., Sr� <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> U <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> 1 <br /> Homeowner or licensed agent's signature certifies the following'."I certify that in the performance of the work for which this rnIa <br /> ermit <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 /> 1 will call for a Grout Inspection prior to grouting and a final lnsp on. <br /> HENNINGS BROS • BY Title- <br /> Date: 10-�8—$2 <br /> Signed X (Draw lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted B <br /> Additional Comments: <br /> Phase 11 Grout Inspection Mas II F' al Inspection <br /> Inspection By Date Inspection By <br /> Date <br /> Fee Is Due'. ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8.Received By January 31 ❑ July 1 &ReceivedREMITuIy 31 <br /> BASE EXPLANATION BILLVNG REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Dat Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by ^� <br /> - Y- <br /> - - <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH 1601 E.HAZELTON AVE.,P.O.Box 2009STOCKTON,CA 95201 PEAMITlSERVICES - <br />