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pp cations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WEIzl� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r <br /> Application is�ereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This appii�.ation is <br /> made in comgiance with San Joaquin County Ordinance No. 1862 and the.rules and regulations of the San Joaquin Local Health District. <br />'. Exact Site Address 16859 W. Rancho Viejo Ct.-Lot 11 Santoscity/Town #3 <br /> Owner's Name J.D. Most Construction Phone 2 <br /> Address _ City <br /> Contractor's Name Hennings-3 <br /> = License#-2908 ' O Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�X No <br />'i TYPE OF WORK (CHECK): NEW WELL EX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ [�} <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1001 Sewer Lines Pit Privy <br /> Sewage Disposal Field 1.0o t-._ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation It <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 100 Ida 11 <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout Cement <br /> ❑ DISPOSAL ❑ OTHER Other Information ;lq'bhby owner <br /> ❑ GEOPHYSICAL Surface Seal Installed By: rd1 le <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 /> 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 Sart Joaquin Local Health District. <br /> Home owner 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 forwhich 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 final ins tion. <br /> Signed Hennings Bros. by Title: Off. Mgri?ate: 7-23.82 <br /> (Draw Plot Plan on Reverse Si ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph e lifirout Inspection Phase Ill Final Inspection <br /> Inspection ByA,E /� Dat�Z.?' y?'� Inspection By Date <br /> / <br /> Fee Is Due: ElANNUALLY El PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 3 s <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �--- 1 D it <br /> Received by 'Dale Receipt No. Permit No. Issuance Date - Mailetl Delivered <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />