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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR oF11ce USE: .APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTHPtMIT PUMP&WELL Q <br /> r r <br /> I (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work"herein described.This application is <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�SANTOS_RANCH E CiDFfQwn <br /> I Owner's Name James Most Phone 835-6921 <br /> i Address 29 E. G ran-tline Rd. City— Tracy, Ca . <br /> r Contractor's Name _. Henning s BrpS s _ License# 2.908 1 A Business Phone <br /> Contractor's Address _152.5 Pe l a ni3 a e, Modesto Emergency Phone -5415-0271 <br /> Is Certificate of Workman's Compensation!Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLE DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tad 100' Sewer Lines Pit Privy r <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 rt <br /> t DOMESTIC/PRIVATE ❑ DRILLED "Dia. of Well Casing 611 PVC <br />` ❑ DOMESTIC/PUBLIC ❑ DRIVEN .160 WALL <br /> � Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB--BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER M <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -may <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: (Well Diameter Approximate Depth r n <br /> I <br /> Describe Material and Procedure b <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> f 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I will call for a Grout Inspection prior to grouting and a final ins ection. <br /> Signed X HENNINGS BROS.. BY �7411 Tit Date: <br /> (Draw Plot Plan on Reverse e) <br /> I FOR DE ARTMENT USE ONLY ; <br /> PHASE I <br /> Application Accepted By&- e <br /> Q / DateAdditional OmmenPhn 1 O Phas JIII�InspectionInspection 8y Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE E 1.XPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> I AMOUNT <br /> FEE C� <br /> LESS I I <br /> PRORATSON [ <br /> PLUS <br /> PENALTY t <br /> I OTHER <br /> OTHER <br /> a <br /> Received by Date 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 />