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_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 27361+ S. Austin Rd.- South end of Aust# T ,• nest to river <br /> Owner's Name Bob Muir Phone ti <br /> Address <br /> 361E S. Austin Rd. city Ripon, Ca . <br /> Contractor's Name Hennings Bros. Drilling Cabense# 290813 Business Phone 1 545-1185 <br /> Contractor's Address 152 5 Pelandale9 Modesto Emergency Phone 545-0271 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No _ <br /> TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 2001+ tSewer Lines Pit Privy <br /> Sewage Disposal Field 2 '+' Cesspool/Seepage Pit Other well 1501 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 20" <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 21* <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 3/16 GA <br /> IRRIGATION GRAVEL PACK Depth of Grout Seal none \•J <br /> ❑ CATHODIC PROTECTION M ROTARY Type of Grout none <br /> ❑ DISPOSAL ❑ OTHER Other Information Slab-by Owner <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <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 I I inspection. <br /> Signed X Hennings Bros, By ;; . e " Date: 4-1 -80 <br /> (Draw Plot Plan on Rev se ide) <br /> FO DEPAR ENT USE ONLY <br /> PHASE <br /> Application Accepted By Date `� o U <br /> Additional Comments: <br /> Phase II Grout Inspection 1phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DA E DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by D to I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />