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Applications Will Be Processed When Submitied Properly Completed. Be Sure To Sign The Application, I! FOR OFFICE USE: APPLICATION .= I (For Non-Transferable, Revocable,Suspendabte) `':� •K I. PUMP&WELL ENVIRONMENTAL HEALTH PERMIT r (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto theSan Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is f made in compliance with San Joagiuin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. + Exact Site Address Rocky PDint R. Lot 32 Stoneridge Sub, City/Town Dale Cose � Owner's Name DaPhone I Address P-0- dX 32 City Tra Cp Contractor's Name Henninks Bros. License# 290813 Businn�ess Phone_} } —0271 w . Contractor's Address 3525 Pelandale, Modesto Emergency Phone L5-.1 12� f Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ € ' REPLACEMENT❑ I� E . a DISTANCE TO NEAREST: Septic Tank _ Sewer Lines Pit Privy l 1 Sewage Disposal Field 100, Cesspool/Seepage Pit Other ' n Property Line Private Domestic Well Public Domestic Well ' INTENDED USE TYPE OF WELL 1, ❑ INDUSTRIAL 1:1 CABLE TOOL Dia. of Well Excavation 11 et `� 1 14 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing � bit PVC ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL ❑ IRRIGATION X GRAVEL PACK Depth of Grout Seal 508 ` r ❑ CATHODIC PROTECTION M ROTARY Type of Grout CEMENT ❑ DISPOSAL ❑ OTHER Other Information SLAB-BY OWNER . ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER PUMP INSTALLATION: Contractor rs Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done r DESTRUCTION OF WELL: Well Diameter. Approximate Depth , Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws,l and rules and regulations of the San Joaquin Local Health District. Homeowner or license dhhhhhh 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 for which this y 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 HENNINGS EROS . BY Date: 12-1 -80 I I�. (Dr w Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY " PHASE I � Application Accepted By_l '�./��G4 C:�� J�=-�Jri Date/2 1 Additional Comments: 11 I Phase If Grout Inspection hase NI Fin Inspection 1 Inspection By Date _ Inspection By 7 Date /.2— 14F ! Fee Is Due: ❑ ANNUALLY I` , �'pI' ❑ PER UNIT ❑ PER SITE "❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE � EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED I AMOUNT FEE I .sb7 LESS PRORATION PLUS , PENALTY I� _ r OTHER � � t �F OTHER--------------------- !' PP Receivecl by of ;I, Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16017 E.,HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 _