Laserfiche WebLink
�. <br />; r —. Applications Will Be Processed When Submitted Properly Compietea. <br /> w APPLICATION 1 <br /> FDR.-6FFTC�USE: <br /> (For Non-,Transferable, Revocable,Suspendable) PUMP&WEAL <br /> 1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> y" WATER QUALITY 1J <br /> (COMPLETE IN TRIPLICATE) ) <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San JTRACY oaquin Gal Health District. <br /> Exact.Site Address LOT 14 UNIT 1 SANTOS RANCH SANTOS CTO City/Town <br /> JAMES MOST Phone $ —621 <br /> Owner's Name City TRA CY <br /> Address 2 E . GRANTLINE RD . 4 —116 <br /> Contractor's Name HHENNINGS BROS . DRILLING COoense# 2908 I Business Phone <br /> 2 PELANDALE MODESTO Emergency Phone 4 —02 1 j <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ss <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 1 <br /> REPLACEMENT❑ Pit Priv <br /> c <br /> DISTANCE TO NEAREST: Septic Tank 00 i Sewer Lines y Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 11 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavationat- <br /> 12 11 DRILLED Dia. of Well Casing Eta PITC <br /> DOMESTIC/PRIVATE � 6 WALL <br /> E-] DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <br /> ❑ IRRIGATION 10 GRAVEL PACK Depth of Grout Seal _ 50 <br /> ❑ CATHODIC PROTECTION IM ROTARY Type of Grout CEMENT <br /> 13 DISPOSAL <br /> 13 OTHER Other information SLAB DRILLER <br /> El GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 4� ❑ State Work Done t PUMP REPAIR: <br /> Approximate Depth <br /> } DESTRUCTION OF WELL: Well Diameter <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 /> V ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> l <br /> Home owner or licensed agent's signature certifies the following,"I certify that in the performance of the work for which this permit <br /> 1 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 wAlh <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will calk for a Grout Inspection prior o r uting and a final i pect' n. <br /> � Da111 11 -28— <br /> Signed <br /> Signed Xraw Plot Plan on Reverse Side)FOR EPARTMENT USE ONLY PHASE 1 11 <br /> I <br /> FApplication Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pf�ase I11 Final inspection <br /> � <br /> Inspection By - <br /> Date a �� 7 Inspection By Fee Is Due: ❑ ANNUALLY 4PRUNIT PER SITE ❑ EACH ❑ January 1 &Received By January 3i �Date <br /> uly 1 &Received IMITuly <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMVTTED AMOUNT <br /> i FEE <br /> LESS <br /> .�. PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Q <br /> f No. Permit No. Issuance Date <br /> Received by Date Receipt Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pERMITISERVICEs <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 <br />