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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION ' (For Non-Transferable, Revocable,Suspendable) PUMP&WELL _ ENVIRONMENTAL HEALTH PERMIT QUALITY (COMPLETE Ifl•'�R1PLfCATE) WATER QQ Applicati8n is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is s 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 SANTOS RANCH EAST LOT 10E SANTOS CT. City/Town Owner's Name James Most Phone 835-6921 a Address 29 E. Grantline Rd . city Tracy Contractor's Name Hennings Bros. License# 290813 Business Phone---5Y5-1185 Contractor's Address 3525 Pelandale Modesto Emergency Phone 545-0271 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 100, Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well f.� INTENDED USE TYPE OF WELL 1 lit ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ("1 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL ❑ IRRIGATION Xj GRAVEL PACK Depth of Grout Seal 501 ❑ CATHODIC PROTECTION 1Z ROTARY Type of Grout CEMENT 0 ❑ DISPOSAL ❑ OTHER Other Information SLAB-BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: _ DRILLER PUMP INSTALLATION: 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 N 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, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:1 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 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 inspecti Signed X HENNINGS BROS . BY � Date: 4-8-80 (Dra Plot Plan on Reverse Side) FOR EPART NT USE ONLY PHASEI Application Accepted By �� Date Additional Comments: Phas Grout inspection _ Phas 11 final Inspection Inspection By Date �� Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED DATE DATE REWTTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER 363_ 4�f&� Received by' - ate Receipt No. Permit No. ssuance Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16o1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON 52 1