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=FOR OwFICE USE: applicationsWill Be# Processed When Submitted Properly Completed. Be Sure To Sign The Application, APPLICATION I (For Non-Transferable, Revocable, Suspendable) ` ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY 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 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 ?01 1 E. French Carn Rd Owner's Name AGRICULTURAL PRODUCST CO. , INC. City/Town d. Address rent am R Phone 982-1031. Contractor's Name HenninnS Eros Drilling City Manteca CLnicerise# 290 13 Business Phone 545-11 Contractor's Address 2 e 80.21 a e d Emergency Phone 54"}-0277 Is Certificate Of Workman's Compensation Insurance on File With SJLHD? Yes x No TYPE OF WORK (CHECK): NEW WELL it DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ WELL CHLORINATION 11 REPLACEMENT 171 WELL ABANDONMENT ElOTHER 11PUMP INSTALLATION 11PUMP REPAIR❑ DISTANCE TO NEAREST; Septic Tank 100 f+ Sewer Lines Pit Privy Sewage Disposal Field 1004 Cesspool/Seepage Pit Property Lino Private Domestic Well1 DO t Other INTENDED USE tublic Domestic Well ❑ INDUSTRIALTYPE OF WELL 0 CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE 2 tt ❑ DOMESTIC/PUBLIC DRILLED Dia. of Well Casing 1211 IRRIGATION El Gauge of Casing �1(� EX GRAVEL PACK Depth of Grout Seal 'Of 13 CATHODIC PROTECTION ❑ DISPOSAL ROTARY Type of Grout Cement ❑ OTHER Other Information Slab b OW72ex' ❑ GEOPHYSICAL PUMP INSTALLATION- Contractor Surface Seal Installed By: Driller � Type of Pump 1 PUMP REPLACEMENT: ❑ State Work Done H.P. L, PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Describe Material and Procedure Approximate Depth I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County h ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit ,tet is issued, I shall not employ an P Y y 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 inspection. s Signed X Rennin S Broa• b Date: 414, - (Draw Plot Plan on ReverseSide) PHASE 1 FOR DEPARTMENT USE ONLY Application Accepted By �wA3-s I Additional Comments: Date Phase It roul nspection M Inspection By Date spection Inspection By A=:;7 Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT I] PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jul i July &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT I DATE DATE REMITTED AMOUNT DUE CHECKED FEE AMOUNT { LESS PRORATION w PLUS PENALTY OTHER ,r OTHER # ` } Received by, Date �� AL3 Receipt No. Permit No Issuance Dae Mailed Delivered APPLFCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STnrrTn,u rx