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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I FoR OFFICE USE: APPLICATION (For Non-Transferable,'Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT QUALITY (COMPLETE IN TRIPLICATE) WATER Q Application is hereby made to the San Joaquin Local Health District for a permit to construct 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 Joaquin Local Health District. j Exact Site Address SANTOS RANCH LOT 23E RANCHO RAMON CT.. _ City/Town Owner's Name JAMES MOST Phone 835-6921 Address 29 E. GRANTLINE RD City Contractor's Name HENNINGS BROS. License#`"29081 3 Business Phone 545-- 185 ul Contractor's Address 1525 PELANDALE II MODESTO Emergency Phone 545-0271 Is Certificate of Workman's Compensation'Insurance on File With SJLHD? Yes x No TYPE OF WORK (CHECK): NEW WELLN DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ I DISTANCE TO-NEAREST: Septic Tank 1 009 Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 1 n V 11 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6!1 PVC j ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing —160 WALL 1 ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 50t ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT. ❑ DISPOSAL ❑ OTHER Other Information SLAB--BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER PUMP INSTALLATION: Contractor -` Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure w 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 forwhich 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 will call for a Grout Inspection prior to grouting and a ff inspection. Signed X - HENNANGS BROSBY SEC. Date: 4-29--80 (DrA Plot Plan on Reverse Si FOR DEPART ENT USE ONLY A PHASEI , Application Accepted By �+^� � 7 - Date__/ jI^A2-a Additional Comments: I P se II Grout Inspection L__1Phase 11 Final Inspection _ f Inspection By Date �� Inspection By Date 5 Fee Is Due: ❑ ANNUALLY ❑ PEJUNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 - BILLING REMITTANCE $ REMIT i - - SASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS i PRORATION t - PLUS : PENALTY OTHER OTHER 0 7o -3,5 q Received by bale - Receipt No Permit No. Issuance Date Mailed Delivered •LLU -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AYE„P.O.Box 2DD9 STOCKTON,CA 9520