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Applications Will Be Processed When Submitted Properly o <br /> M <br /> USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pUf,Ap&WEtI ENVIRONMENTAL- HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with SaJoaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, 4 <br /> Exact Site Address LOT b UNIT 1 SANTOS RANCH GRUNAUER RD Qty/Town <br /> JAMES MOST phone U_5_n6921 <br /> owner's Name 9 GRANTLINE RD . City TRACY <br /> Address NNINGS BROS . DRILLxNG C 290 1 Business Phone 1 85 <br /> L�cense# }+ -02 1 <br /> Contractor's Name A A E MODESTO Emergency Phone <br /> Contractor's Address X No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): WELEW L ABANDEEPENDONMENT <br /> DONMENT 1:1❑ OTFiRECONDITION <br /> PU❑MP INSTALLATIONO❑❑ PUMP REPAIR❑ <br /> WELL CHLORINATION <br /> REPLACEMENT❑ pit Privy 1 <br /> DISTANCE TO NEAREST: Septic Tank 100 1 Sewer Lines <br /> Cesspool Pit Other <br /> Cess _ <br /> Sewage Disposal Field p <br /> Property Line Private Domestic Well Public Domestic Well �Y <br /> INTENDED USE TYPE OF WELL Es <br /> ❑ INDUSTRIAL E] CABLE TOOL Dia. of Well Excavation <br /> - <br /> El <br /> ❑ DRILLED Dia. of Well Casing 6rt PV f <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r <br /> ❑ IRRIGATION GRAVEL PACK-- Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY - --Type of Grout CE N <br /> LOther Information B—❑ DISPOSAL 13 OTHER RILLS <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> jApproximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> j� 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 for which this permit <br /> i is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> 1 Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California.' <br /> I will call for a Grout Inspection prior to grouting and a final inspec ' n <br /> Signed X <br /> KENNINGS BROS. BY Date: -2$- <br /> { aw Plot Plan on Reverse Side) <br /> OR EPART NT USE ONLY r�r <br /> PHASE IM <br /> Application Accepted By <br /> 1 Additional Comments: as I Final Inspection <br /> 1J Phase 11 Grout Inspection <br /> Iate inspection By ate <br /> Inspection By .-. �K Iv_ .L��7 <br /> I Fee IS Due: ❑ ANNUALLY X ❑ PER NIT LA PER SITE ❑ EACH ❑ January 1 Re lived By January 3 July 1 &ReceiveRdEB1yITu1y 31 <br /> i AMOUNT DUE CHECKED <br /> i BILLING REMITTANCE � <br /> 1I gpgE EXPLANATION + DATE DATE REMITTED AMOUNT <br /> it FEE <br /> t .S <br /> �. LESS -` <br /> r PRORATION . <br /> PLUS <br /> PENALTY s <br /> � OTHER <br /> 1" OTHER <br /> r -70 �7 1Z <br /> Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> Received by 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON;CA 95201 <br /> I - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />