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Applications Will Be Processed YPhen'Submitted Properly Completed. Be Sure To Sign'The Application. FOR OFFICE USE: APPLICATION (For Non-Translerable, Revocable, Suspendable) a ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) y WATER QUALITY _ Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is . .r t 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 SANTOS RANCH LOT4E RANCHO RAMON DR. City/Town _ Owner's Name JAMES MOST Phone 835-6921 Address 29 E. GRANTLINE RD. C;ty " TRACY Contractor's Name HENNING S BROS. License#29081- Business Phone 545-11.05— Contractor's 45--11$5Contractor's Address _ 525 PELANDA!41 MODES.TO Emergency Phone 545-0271 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No G} ? TYPE OF WORK (CHECK): NEW WELL'X DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ d WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank; 100 t Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE ' TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 1 it (vvn DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC _. ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL j ❑ IRRIGATION IX GRAVEL PACK Depth of Grout Seal .. 0 t ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT ❑ DISPOSAL ❑ OTHER Other Information SLAB–BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER 0 ' PUMP INSTALLATION: Contractor Type of Pump H.P. ' PUMP REPLACEMENT: ❑ State Work Done 1 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 t i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit er 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California," - I will call for a Grout Inspectionpriorto grouqlDg and a inspection. - Signed X HENNINGS BROS. BY SEC. Date: 4-29-80 (Dr 'Plot Plan on Reverse e) F R DEPA TMENT USE ONLY i PHASE t Application Accepted By ✓� P Date a G Additional Comments: - f Phase II Grout Inspection P ase III i Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER'U%T La PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 r BASE EXPLANATION BILLING REMITTANCE $ REMITAMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT { FEE ! LESS PRORATION PLUS ' _PENALTY ,. OTHER . 1 OJAI OTHER2>0 .rte k li Received by. Date t Receipt No,^ Perm#t Na - - Issuance�Dale— - MailedDeliveredAPPLICANT_—RETURN ALL COPIES TO: ENVIRONMENTAL"HEALTH PERMIT/SERVICES E:HAZELTP.O.-Box 2pp97!2 T CKTON,CA 95291'