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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) �+� 4y PUllh�&WELL ENVIRONMENTAL HEALTH PERMIT �� o � (COMPLETE IN TRIPLICATE) WATER QUALITY 1 Application is hereby madeto the San Joaquin Local Health Districtfora permitto coristruct and/or install the work herein described.This'applicationis made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District'` G Exact Site Address SANTOS RANCH EAST LOT 1 6E RANCHO RAMON 1DFk/,Town Owner's Name Jame s- MOSt Phone Address 29 E City Tr — Contractor's Name Hennin 5 BrosLicense#'2 0811 Business Phone �5-1 1 85 Contractor's Address e�a.ndale Modesto Emergency Phone 545-0271 Is Certificate of Workman's CompensationInsuranceon File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ \l` DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE t TYPE OF WELL 'i. ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing 611 PVC - Q ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL" ' �f F ❑ IRRIGATION 2 GRAVEL PACK Depth of Grout Seal e ❑ CATHODIC PROTECTION ROTARY Type of Grout CTt ❑ DISPOSAL OTHER Other Information t ❑ GEOPHYSICAL Surface Seal Installed By: .. DRILLER PUMP INSTALLATION: Contractor j Type of Pump yH.P. - PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure s F� 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 performanceof thework 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 I will call for a Grout Inspection+prior to grouting and a final inspection. Signed X HENNINGS BROS. BY1e t -r4 � Date: 4— _ (Draw Plot Plan on Reverse Side) r ( FO DEPART SENT USE ONLY PHASE I •j Application Accepted By Q Date v " Additional Comments: P e II Grout inspection / r Pha I11, al Inspection Inspection By Date Inspection By Date go If Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH El January 1 &Received By January 31 13 July 1 &Received By July 31 ll BILLING. REMITTANCE $ REMIT a ' - BASE EXPLANATION AMOUNT DUE` CHECKED DATE DATE REMITTED AMOUNT #' €. FEE i LESS + PRORATION ' :I PLUS PENALTY OTHER OTHER d osl 'Received by Date - Receipt No, Permit No. "=----'=��lssuance Date «.Mailed — Delivered r-•x._ APPCICA_NT--RETURN-ALL COPIES TO:. ENVIRpNMENTAL'HEAL'TH'PERMITISERVICES � '1601 E.HAZELTON�AVE,p.O�'8ox 2009 STOCKTON,CA 95201