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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: - APPLICATION <br /> (For Non-Transferable,`W6VO ab4, Suspendable) -�— <br /> r, <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> WATER QUALITY. <br /> (COMPLETE IN TRIPLICATE) a <br /> 1 , <br /> 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 (v <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulatio f the San Joaquin Local Health District. <br /> Exact Site Address SANTOS RANCH EAST LOT-20E RANC 0MID Cly Town <br /> Owner's Name J Phone_815-6 21 <br /> Address 29 E. Cxr�t�[ � n . Rr7 City Tr=T f <br />. _ Tracy <br /> Contractor's Name Hennirn s Bros• License# 29081,3 Business Phone 545 <br /> Contractor's Address 3525 Pelandale.. Modesto Emergency Phone . 54, -0271 - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK(CHECK): NEW WELUIX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Cy <br /> DISTANCE TO NEAREST: Septic Tank I loot Sewer Lines Pit Privy 11 � <br /> Sewage Disposal Field.. Cesspool/Seepage Pit Other W <br />` Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation_ 1 lit - \I <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC <br /> ❑ DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing 16b wA,T.T. +? <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal0 t <br /> I <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT h1 <br /> ❑ DISPOSAL_ ❑ OTHER Other InformationALAR—BY <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRITIER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done x <br /> PUMP REPAIR: ❑ State Work pone ;+ <br /> DESTRUCTION OF WELL: Well Diameter, - Approximate Depth <br /> r <br /> Describe Material and Procedure <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and.regulations of the San Joaquin Local Health District. ' p <br /> Homeowner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which 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 5 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> f <br /> Signed X Date: — — <br /> (Dra4 Plot Plan on Reverse Side) <br /> �TENT USE ONLY <br /> PHASE I <br /> Application Accepted By _.. Date <br /> Additional Comments: <br /> PlAse II Grout Inspection PhaseMnal inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUAL Y ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED .AMOUNT DUE CHECKED <br /> AMOUNT <br /> I FEE L�3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 90 I <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered I <br />�, APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 952 <br />