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Applications Will BeProcessedWhenSubmitted ProperlyCompleted. Be SureToSignTheApplication. FOR Ut,iCE,USE: APPLICATION ;., (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 8858 S. PRIEST City/Town MANTECA, CALIF owner's Name ASH CONSTRUCTION Phone 577--4517 Address 407 HOSMER AVE. City MODESTOj Contractor's Name HENNINGS BROS. License#290$13 Business Phone 545-11 $5 r Contractor's Address 3525 PELANDALE AVE. Emergency Phone 545--0271 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No 7 TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i WELL CHLORINATION ❑ WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 150 Sewer Lines 150 t Pit Privy Sewage Disposal Field 150 t _ Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation 13 tt 11.DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing !t 1 11 DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing 1 0 PVC ❑ IRRIGATION XXGRAVEL PACK Depth of Grout Seal 50 t ❑ CATHODIC PROTECTION 1XROTARY Type of Grout BENTONITE ❑ DISPOSAL ❑ OTHER Other Information SLAB BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER PUMP INSTALLATION: �2 Contractor Type of Pump H.P, PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ob 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. vu Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this 77!" permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X HENNTNGS BROS. DRILLING GO,INCTItle: Juli Surr'att, Date: 6-25-81 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Date Additional Comments: 2 ;1ryk_Va II Gr 1 Inspection Ph 11 Final Inspection Insp ct� ion B Date Inspection By ate Fee Is Due: 13 ANNUALLY El PER UNIT 11 PER SITE El EACH C3 January 1 8 Received By January 31 July 1 &Received By July 31 REMIT BILLING REMITTANCE $ ED BASE EXPLANATION DATE DATE REMITTED AMO NT DUE CHECKAMOUNT AMOUNTT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by D to Receipt No. Permit No Issuance Date Mailed Deiivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201