Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ccs USE: <br /> APPLICATION S1, <br /> Z- (For Non-Transferable, Revocable,Suspendable) ! <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELE` <br /> j WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work:hereindescribed.This application is <br /> I <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 LOT 6 UNIT 1 SANTOS MGH RANCHO RA�ipRlc on <br /> Owner's Name JAMES MOST Phone 835-6921 <br /> Address 29 E . GRANTLINE RD. City TRACY _ <br /> Contractor's Name HENNINGS BROS . DRILLING C0oe9se# 290813 Business Phone 545-1885 <br /> Contractor's Address —a525 PELANDALE . MOD. Emergency Phone .545-02.71 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1 001 Sewer Lines Pit Privy - <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br />`1 Property Line Private Domestic Well Public Domestic Well <br /> ff INTENDED USE TYPE OF WELL <br /> Cl INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation 1 1 His <br /> DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing 6" PV a <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL e— <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal 50 <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material.and Procedure <br /> 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 Cail — <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forw <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 inspec <br /> 1 <br /> Signed X f Date: 8— <br /> (D aw Plot Plan on Reverse Side) <br /> ORD PARTMEN USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III Final Inspection <br /> Inspection By C Date i��/ `7/7 g Inspection By Date <br /> �r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER S1TE © EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br />` BILLING REMITTANCE $ REMIT <br /> Et BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION isw <br /> PLUS <br /> PENALTY } <br /> OTHER 3 <br /> OTHER t, - M1.. +,r• _ <br /> Received by _ Elate Receipt No. Permit No. -Issuance Date � Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />