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pliatitsr1lsedWhen Submitted Property Completed. Be Sure To Sign The Application. FOR OFFI SE: APPLICATION Y r98o (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE lWYNIPLOMPUIN LeA WATER QUALITY Application is her �� t®�Ir}Qr- tocalHealth District for apermit toconstruct and/or install the work herein described.Thisapplicationis made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District f Exact Site Address SANTOS RANCHO LOT 18 ANCHO RAMON CT. City/Town TRACY i Owner's Name JAMES MOST Phone 835-6921 Address 29 E. GRANT INE RD City TRACY1 II Contractor's Name HENNINGS BROS. License# 29081 Business Phone LF - UJ - k Contractor's Address PELANDALE, MODEST© Emergency Phone' ; 45-02-71 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No TYPE OF WORK (CHECK): NEW WELL EX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 100 t Sewer Lines !' Pit Privy � Sewage Disposal Field = Cesspool/Seepage Pit Other s— Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Z Dia. of Well Excavation tt DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge.of Casing 160 WALL ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501 ❑ CATHODIC PROTECTION I$ 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 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.performance of the work 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." t I will call for a Grout Inspection prior to grouting and a linal 1 pection. Signed_ X HENNINGS BROS.. BY Date: —2--80 (Draw Plot Plan on Reverse S' e) FORDEPARTMENT.-US O E ONLY (\ PHASE I Application Accepted By Date Additional Comments: ha Grout Inspection Phas "111 Final Inspection Inspection By Dateh '� Inspection By Date Fee Is Due: ❑ ANNUALLY El PER UNIT 11 PER SITE ❑ EACH ❑ January 1 &Received By Jan ary 31 ❑ Juiy 1 &Received By July 31 REMIT BILLING REMITTANCE- $ i - BASE EXPLANATION - DATE .DATE, REMITTED AMOUNT DUE CHECKED II rf `f AMOUNT FEE LESS PRORATION PLUS PENALTY .. OTHER .. OTHER -6 s6 7 Received by Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1