Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> O13 OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) n <br /> PUMP&WI=LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETEINTRIPLICATE) WATER QUALITY <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 <br /> made in compliance with San Joa uin County Ordinance No. 1862 and the rules and re ulations of the San Joa uin L al Health District. _�N <br /> Exact Site Address LOT 1 '7 INIT 1 SANTOS RANCH RANCHO RgAM9y/9otvR TRA C11 <br /> Owner's Name JAMES MOST <br /> Phone 5--6921 <br /> Address 29 E . GRANTLINE RD. City TRACY <br /> Contractor's Name HENNINGS BROS. License# 290813 Business Phone —1 185 <br /> Contractor's Address 525 PELANDALE , MOD. Emergency Phone 545-0271 r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines Pit Privy <br />! Sewage Disposal Field Cesspool/Seepage Pit Other___ C <br /> Property Line Private Domestic Well Public Domestic Well <br />! INTENDED USE TYPE OF WELL <br /> ElINDUSTRIAL 11CABLE TOOL Dia. of Well Excavation 1 lit. <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC n <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501. <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CEiviENT <br /> ❑ DISPOSAL ❑ OTHER Other Information LAB—BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County o <br /> ordinances, state laws, and rules and regulations of the San.Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work_forwhich 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 will call for a Grout Inspection prior to gr ting and a final inspec ' n <br /> Signed X HENNINGS BROS. BY _ s Date: 1 1 —28—']g <br /> 1 ( raw Plot Plan on Reverse Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASE I <br /> t <br /> Application Accepted By Date <br /> Additional Comments: <br /> Pha a II Gr It Ins ion P ase III Final Inspection <br /> Inspection By j _ ction By Date - <br />, � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> EASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> } AMOUNT <br /> FEE <br /> LESS _t <br /> PRORATION <br /> PLUS - — <br /> PENALTY <br /> OTHER - -- <br /> OTHER <br /> L <br /> Received bye bate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT.ON,CA 95201 <br />