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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) - PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN (PLICATE) 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 oft e San Joaq I Locgl ealth District. Exact Site Address 30261 S. Airport Way-JI-Mi. east of KassW- y/ n, norslue i Owner's Name Manteca Sportsman Club Phone 537-3602 Address 30261 S . Airport WaY City Manteca �) Contractor's Name Hennings Bros. License# 290811 Business Phone 545-1185 Contractor's Address 1525 Pelandale, Modesto Emergency Phone 545-0271 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_. X No TYPE! OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ RERLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 100` Sewer Lines _ Pit Privy -- Sewage Disposal Field__ 100 1+ Cesspool/Seepage Pit _ Other__ Property Line Private Domestic Well 401 Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 art ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 81t 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 6' 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 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 will call for a Grout Inspection prior to grouting and (nal inspection. Signed X Hennings Bros. by Sec• Date: 7-8-80 (Draw Plot Plan on Re rse Side) FOR DEPART NT USE ONLY s PHASE M Application Accepted By ' 1 vim— Date Additional Comments: Phase 11 Grout Inspection Phase III Final Inspection Inspection By Date ��\� Inspection By �, Date �_. \ \:a Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER (3 Received by Datb Receipt No. Permit No. Issuance Date Mailed DeliveredP APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201QiP