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Applications Will'Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: it APPLICATION <br /> k (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY f <br /> t <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application.L <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 LOT —1 6 00N9R i Ac <br /> ►. <br /> O�ner's Name J.D. MOST CONST. Phone 8,35-6921 <br /> Address 29 E. GRANTLINE RD. City TRACY <br /> Contractor's Name EENNINGS BROS. License# 29081J Business Phone 545-1185 <br /> Contractor's Address3525 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 IX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ V 1} <br /> REPLACEMENT❑ [J�] <br /> DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines Pit Privy C>O <br /> Sewage Disposal Field 100" Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I� TYPE OF WELL <br /> ❑ INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation 11 tr <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 61' PVC <br /> ❑ DOMESTIC/PUBLIC ; ❑ DRIVEN Gauge of Casing 160 WALL <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION IX ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER _ <br /> Ij <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done rJ <br /> PUMP REPAIR: ii ❑ State Work Done v t! <br /> DESTRUCTION OF WELL: r Well Diameter Approximate Depth <br /> i1 Describe Material and Procedure .4 <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 subjbct to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouiin and a final ins a ion. <br /> Signed X _H'NNINGS BROS. BY ri Date: 10-8-82 <br /> {Draw bot Plan on Reverse Side} <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted Cfl Date <br /> Additional Comments: i <br /> Phase II Grout InspectionPhos InaE Inspection <br /> Inspection By '2- it Date 2- I-S'? Inspection By �+-- Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By.July 31 <br /> REMIT <br /> BASE EXPLANATION 1 BILLING REMITTANCE $ AMOUNT'DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE i E <br /> LESS e <br /> PRORATION <br /> PLUS # <br /> PENALTY f <br /> OTHER #1 <br /> OTHER <br /> ID �`�, <br /> Received by - Date Receipt No. Permit.No. - Issuance Date - - Mailed Delivered - <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 —Y- <br />