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s�ilclbe604ssi9i ubmitted Property Completed.-Be Sure-To Sign The Application. <br /> W <br /> FOR OFFICE USE: !J APPLICATION <br /> 1Jrr Non-Transferable, Revocable,SuspendableypAY <br /> t ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICAT6AN J06101Y'i -' l�),C` `AL WATER QUALITY <br />!! Application is hereby madetotl,VEAL1 iia14 191Q1;Districtforapermittoconstructand/or install thework 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 LOT 19 RANCHO RAMON '-CT City/Town ­ TRACY <br /> Owner's Name JAMES MOST — Phone—8-3.5-6921oC� <br /> _ <br /> Address 29 E. GRANTLINE R City TRAry <br /> Contractor's Name HENNINGS BROS. License`#;?_q081-3 Business Phone. <br /> Contractor's Address 3525 PELANDALE MODESTO " 'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK (CHECK): . NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 13 =` <br /> DISTANCE TO NEAREST: Septic Tank 1001 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line- Private Domestic Well Public Domestic Well <br /> i INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> Z DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6" PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ 160 WALL <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information S1AB--3y OWNER _ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, W <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Dane <br />;i DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />` Describe Material and Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent'stsignature certifies the following:"I certify that in the performance of the woirk for which this permit <br /> is issued, I shall not employ an' <br /> y person in such manner as'to become subject to workman's compensation laws of California." <br /> k 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 grouting and a fin^ inspection. <br /> Signed HENNINGS BROS. BY SEC 0. Date: —2— <br /> (Draw Plot Plan on Reverse e) <br /> i - - <br /> FOR DEPARTMENT LIKE ONLY <br /> PHASE [ <br /> Application Accepted By Date <br /> EAdditional Comments: <br /> E <br /> Phase It Gro specllon Phas Final Inspection <br /> Inspection By Date �1&q* Inspection By Date 7 3 <br /> s <br /> Fee Is Due: ❑ ANNUALLY 1:1 PER UNIT E] PER SITE 13 EACH '❑ January 1 S Received By Ja uary 31 ❑ July 1 R Received By July 31 <br /> BILLING - REMITTANCE $ REMIT <br /> I BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br />€ FEE `13 q3 <br /> LESS - <br /> PRORATION - - <br /> PLUS - <br /> i PENALTY - <br /> OTHER <br /> OTHER <br /> 9� R) 7 <br /> Received by Date Receipt No. 'Permit No. - Issuance Date Mailed - Delivered , <br />., -APPLICANT—RETURN ALL COPIES TO: w ENVIRONMENTAL HEALTH PERMIT/SERVICES_ - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO"C 1 <br /> - { <br />