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Applications(Will Be-Processed When Submitted ProperlyCompleted. BeSureTosign ineAppncacran. FOR OFFICE USE: 4 APPLICATION (For Non-Translerable,'Revocable,Susp&dable) �pUMP&WELL ENVIRONMENTAL HEALTH PERMIT ' (COMPLETE IN TRIPLICATE) WATER QUALITY cation is Application ishereby'madetothe San Joaquin Local Health Districtforapermittoconstruct and/or install the work herein described.This appli made in compliance with San Joaquin County Ordinance No..1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addressl f-E o H` 120-fit i. east of French CarrCptyRl 11 north side Owner's Name Fischer Nursery Phone 98 ?-1670 City Manteca Ca . Address 1 ,774? E e H 1 20� ' I Drilling Cok,,ZVA. 2 081 ' Business Phone— Contractor's hone Contractor's NameHenr3in�S Bros• 1 Contractor's Address1525 525 Pelandale 9 Modesto Emergency Phone � Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No q TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] C} WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1 �O Sewer Lines Pit Privy. ! + Cesspool/Seepage Pit OtherWell Sewage Disposal Field. 1 001 2 Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL --' 11 tr 11 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation 1 ❑ DRILLED Dia. of Well Casing 6tt PVC DOMESTIC/PRIVATE 1 11DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing 60 WALL ❑ IRRIGATION M GRAVEL PACK Depth of Grout Seal 501 ❑ CATHODIC PROTECTION ® ROTARY Type of Grout BENTONITE 4 ❑ DISPOSAL ❑ OTHER Other Information SLABIBY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER SI J PUMP INSTALLATION: Contractor Type of Pump H.P. �} PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter DApproximate Depth Describe Material and Procedure F Q 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance ofthe work forwhich this permit j is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 11 Contractors 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 r " 4 1 will call for a Grout Inspectio nor to grouting and a final inspection. Signed X Title:` Date: 8-8-79 - raw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE L9 7 Application Accepted By Date Additional Comments: Pha Grout I spection '111 Fin i Inspection ..� Inspection By Date � Inspection By Date - b Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received Ry January 31 ❑ July 1 &Receive REMITuiy 31 BASE 'EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED f DATE DATE REMITTED AMOUNT FEE LESS V PRORAT4ON b PLUS PENALTY 1 I OTHER 4 w OTHER 31Sg I` Received by Date { Receipt No, Permit No. Istuancla Date - Mailetl Deliveretl 4, APPLICANT—RETURN ALL COMES TO: `!ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201