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.2. Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR DICE USE: APPLICATION <br />` (For Non-Transierable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL j <br /> r <br /> a (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 0� <br /> 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 lJl <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re ulationofth San Joaquin Local Health District. <br /> Exact Site Address LOT .3 UNIT 1 RANCHO RAMON DR. SANTOS d1, <br /> Owner's Name James Most Phone 835-6921 <br /> Address 29 E . Grantline Rd . c;ty racy <br /> Contractor's Name Hen nin S Bros . Drilling CQicense# 290813 Business Phone 545-1185 <br /> Contractor's Address 3.5 ndale Ave. , Mod . Emergency Phone 545-0271 <br /> Is Certificate of Workman's Compensationlnsurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL X DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL. ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> l REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 100 1 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation 1 lit- <br /> DOMESTIC/PRIVATE <br /> tt DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC <br /> t ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 0 WALL L' <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION I ROTARY Type of Grout .. CEMENT f <br /> ❑ DISPOSAL ❑ OTHER Other Information SAB OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> f PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: a ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> I 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 /> Home owner 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 California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Insp,ggtion prior to grouting and a final inspec(�on. - <br /> Signed X Title: �(/ 1• Date: 11 -28-79 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> f PHASE <br />' Application Accepted By "` Date <br /> Additional Comments: f <br />' Ph e,II out Ins ion Ph III-Final Inspection <br /> ti <br /> InspectionByin.. to k � Inspecti Date <br />[ .. Fee IS Dile: ❑ ANNUALLY ❑ PER UNITIPX(PER SIT ❑ EACH ❑ January ceived By January 31 ❑ July t &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATkON AMOUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed . Delivered <br /> l,` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES A601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />