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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' FOR OFFICE USES APPLICATION —� ( (For Non-Transferable, Revocable, Suspendable) —a PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) 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 t7Q 4 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 LOT 15 UNIT .1 SANTOS RANCH RANCHO. RAMCRy$&1 TRACY Owner's Name JAMES MOST I Phone 835-6921 Address 29 E GRANTLINE RD . City TRACY " Contractor's Name HE,NNINGS BRO'S o License#. 290813 Busin ss Phone .545-1185 Contractor's Address 3525 PELANsDALE7.--.M._O—D.._._-._. -0271 _€mergency Phone5 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No t TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑ f WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT[] DISTANCE TO NEAREST: Septic Tank loot Sewer Lines Pit Privy _ Sewage Disposal Field Cesspool/Seepage Pit Other /!! Property Line Private Domestic Well Public Domestic Well /1 _ r INTENDED USE TYPE OF WELL Q' W El INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 tL DOMESTIC/PRIVATE ElDRILLED Dia. of Well Casing 611. PITC i ❑ DOMES'T'IC/PUBLIC E3DRIVEN Gauge of Casing 160 WALL ❑ IRRIGATION M GRAVEL PACK Depth of Grout Seal 501 1 ❑ CATHODIC PROTECTION M ROTARY Type of Grout CEMENT 4 ❑ DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER # PUMP INSTALLATION: Contractor Type of Pump H,P. - fi 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 l 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 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 Inspection pri[orwto outing and a Fina-ins ct" n. L Signed X KENNINGS BROS. BY `{ 11e:/ s Date: 11 -28-79 (Draw Plot Plan on Reverse Sid v t FOR EPARTMENT USE ONLY PHASE / Application Accepted By Additional Comments: Phase 11 Grout Inspection Phase III Final Inspect on inspection By Date s ecfiori By Date Fee IS Dile: ❑ ANNU LY Y El UNIT PER ITE EACH ❑ January 1 a Received By nary 3 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ i BASE EXPLANATION AMOUNT DUE CHECKED _ DATE DATE fiEMITTED AMOUNT FEE 44/ 1! LESS PRORATION + PLUS # PENALTY # r OTHER OTHER m Received by - Dale - - Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ./