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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> FOR oFFlce USE: <br /> (For Non-Transferable, Revocable, Suspendable) PL1Mp &WELL <br /> ENVIRONME TTL HEALTH PERMIT <br /> } <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora 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 Joaquin Local Health District. O <br /> Exact Site Address SANTOS RANCH EAST LOT 1 E SANTOS CT. City/Town <br /> I <br /> g -.6 21 <br /> Owner's Name James Most Phone <br /> Address 29 E. Grantline Rd city IT - <br /> License# 2 081 Business Phone )+ -1 8 <br /> Contractor's Name Hennings Bros. LF —02 <br /> Contractor's Address. Peland l8 MQdeO Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ W <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1 oos Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other .i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 11 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 6" PVC <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 160 WALL <br /> ❑ DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> ❑ IRRIGATION I$GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT a <br /> ❑ OTHER Other Information SLAB-BY OWNER <br /> 11 DISPOSAL <br /> 13 GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> O <br /> PUMP REPLACEMENT: ❑ State Work Done d' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure +� <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. p <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit t <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 i1 i <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 flnal inspection. <br /> Date: 4-8-8o <br /> Signed X HENNINGBRO BY <br /> (Dra lot Plan on Reverse Side) <br /> FOR EPAR ENT USE ONLY <br /> I PHASE Q Date <br /> 7 9 <br /> 1; Application Accepted By / <br /> Additional Comments: <br /> Phas Gro ection t Phase III Final Inspection J <br /> Inspection By <br /> to `-'l Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE El EACH ❑ January 1 Received By January 31 © July 1 &ReceivedREMITuly 31 <br /> A BASE EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> y OTHER <br /> OTHER <br /> _gp c3 5367 Is &o <br /> F 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, 1 <br />