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ApplicationsWillBe Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I APPLICATION <br /> I (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE TN TRIPLICATE) WATER QUALITY *. <br /> Appl ication 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 <br /> ma6e in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. a <br /> Exact Site Address 1626r.7 W: R2 ny ho Viejo Ct.-Lot 10 S2 ntority/Town #3 <br /> O r'sName J.D . Most Construction Phone 835-6921 <br /> Address 29 E . Grantline Rd. city Trac S <br /> Contractor's Name Hennings Bros . License# 290813 Business Phone <br /> Contractor's Address 3525 P a nd a l e Ave* , Mode S teergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No t <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V`� , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> �J <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 100 t Sewer Lines Pit Privy { <br /> Sewage Disposal Field 100 1' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Weil Public Domestic Well 1 <br /> INTENDED USE TYPE OF WELL tt <br /> ❑ INDUSTRIAL i, ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE I ❑ DRILLED Dia. of Well Casing 6" PVC <br /> ❑ DOMESTIC/PUBLIC ; ❑ DRIVEN Gauge of Casing 160 Wall , <br /> ❑ IRRIGATION I M GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION j ROTARY Type of Grout Cement r <br /> 11DISPOSAL j' OTHER Other Information Slab—by Owner <br /> ❑ GEOPHYSICAL II Surface Seal Installed By: Driller <br /> PUMP INSTALLATION: I Contractor <br /> Type of Pump H.P. • ) <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I� ❑ State Work Done <br /> DESTRUCTION OF WELL: '! Well Diameter Approximate Depth <br /> :I <br /> Describe Material and Procedure <br /> IS <br /> r ' <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. <br /> Homeowner or licensed agent's signature certifies the following:"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 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 tgr_o,,u�ttiing and a final mspecti n. I <br /> Signed X Hennings Bros. ` Y ®�Il�rr!e�c xil Off Mgr. Date: 7-23-82 G' <br /> (Dr(aw Plot Plan on Reverse Sid- , <br /> 4 zz <br /> �i FOR DEPARTMENT USE ONLY <br /> i <br /> i PHASE I <br />` Application Accepted By <br /> Date <br /> Additional Comments: A <br /> Pha �A'!:= <br /> Inspection Phase III Final Inspection <br /> Inspection ByDate—7-7 7-F Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ij❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By.January 31 ❑ July 1 &Received By July 31 <br /> „ REMIT <br /> BASE I' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> �(3 <br /> LESS l <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> E'OTHER � <br /> i <br /> �1 � ] J <br /> Received by I Oat :l Receipt No ' Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />