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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplication, _:ICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL 7 T ENVIRONMENTAL HEALTH PERMIT �. .�(COMPLETE IN TRIPLICATE) '' S�(8 1�c �G�'E - WATER QU LITY € ` ( l t 7wP Application is hereby made to the San Joaquin Local Health Distract or permi t o consf"ruct and/or install.the work herein described.this application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Jo a uln Local Health District, Exact Site Address LOT UNIT 2 SANTOS RANCH RANCHO RAMC�y/Town TgRACY Owner's Name JAMES MOST phone 835-6921 Address 2 E . GRANTLI RD . City Contractor's Name HENNINGS BROS. License# 290 13 5�n5 0271 - 1 Contractor's Address 2 PELANDALE MOD . Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No k TYPE OF WORK (CHECK): NEW WELLQ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other I Property Line Private Domestic Well Public Domestic Well t INTENDED USE TYPE OF WELL 1 1 YI i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation M DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 66 ALL } ElDOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing ❑ IRRIGATION IN GRAVEL PACK Depth of Grout Seal 50= ROTARY Type of Grout CEMENT = J ❑ CATHODIC PROTECTION B--BY OWNER. ❑ DISPOSAL El OTHER Other Information DRILLER 11 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done i DESTRUCTION OF WELL: Well Diameter Approximate Depth _ • Describe Material and Procedure �r 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. Homeowner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for which this permit s 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." 7 i I will call for a Grout Inspection prior to grouting and a final 'n ecti ` Signed X N G BROS. BY Date: 11 -28-79 ( aw Plot Plan on Reverse Side) r FOR DEPARTMENT USE ONLY t .. PHASE I i Application Accepted By C Date Additional Comments: 1 Phase II Grout Inspection Phase III Final Inspection Inspection By. ate �- Inspectio ate Fee Is Due: ❑ ANNUALLY ❑ PEA UNIT PER SITE ❑ EACH ❑ January 1 eceived By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE I LESS PRORATION PLUS l PENALTY I OTHER OTHER r� S 70 Received by _ Date --..receipt No - Permit Noa Issuance ate Mailed Delivered 0. AVE.,P.O. PCICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.'HAZELTON _9oY 2009 STOCKTON,CA 95201