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Applt sPleP.focrssedV"nS fitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE. " , \..l ( PPLICATION <br /> t <br /> (For Non-;� erable, Revocable, Suspendable) 1'. 2 <br /> MAY 5 "RONMENTAL HEALTH PERMIT PUMP&IWIELL <br /> (COMPLETE IN TRIPLICATE) �q � I t - (� f- WATER QUALITY <br /> Application is pliant ymadetothet it 1Jbaatri i' K(��i'Ictforapermittoconstructand/orinstallthework herein described.This application is <br /> made incompliance with San Joaq I 1 t i6J.1 862 and the rules and re ul 'on t i cal H str' <br /> Exact Site Address RIVER RD.- MT. NORTH OF RIVER RD. W E`S iT6��MRT, HD. , WbT 6 CANAL <br /> Owner's Name JERRY'-HANSEN Phone 838-7552 <br /> 2 ��rSU—r�6 <br /> Address RT 1 BOX 1+18 City <br /> Contractor's Name HENNINGS BROS', License# 081 Business Phone _e 1 1 A5 <br /> Contractor's Address 3525 PELANDA MO - Emergency Phone545 0 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�. X_ No <br /> TYPE OF WORK (CHECK): NEW WELLZI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR —9 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 100t+ Sewer Lines Pit Privy C1� <br /> Sewage Disposal Field 1 00t-I- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ^O <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 11 n (h <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL <br /> ❑ IRRIGATION 1Z GRAVEL PACK Depth of Grout Seal 50 t <br /> ❑ CATHODIC PROTECTION IX ROTARY Type of Grout BENTONITE <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB-BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <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 /> 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 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 for which 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 fine spection. <br /> Signed X <br /> HENNINGS BROS. <br /> _ _ BY SEC- Date: I�-2g-$O ; <br /> (Draw Plot Plan on Reverse Si ) <br /> FOR DEPARTMENT US'ONLY <br /> PHASE <br /> Application Accepted By _ Date SJrc Bd <br /> Additional Comments: <br /> P ase 11 Grout Inspection hase III Final Inspection 77 �r�� <br /> Inspection By Date t- Inspection 8y Date J!1"� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE l� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Oate Receipt No. Permit No. Issuance Date Mailed Delivered , <br /> t' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O,Box 2009 STOCKTON,CA 85201 <br />