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e App i@ jgY6&rAe°t .Ah bmitted Properly Completed:Be SureToSign tineAppal-11-1• <br /> FOR OFFICE USE: <br /> APPLICAT1011 - - ',` . <br /> MAY 5 1�1Non- ransferabfe, Revocable,'Suspendable) pUMp&WELL <br /> _ - . <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ` SRN .,IAF.=✓}�� ! LOCAL WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) r <br /> Application ishere,�ymade tothe��a��""inEo4�I���Districtforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationls I, <br /> ?Wade in compliance with San Joaquin County Ordinance No. 1862 and the rules and regu�t' ns the San Joaquin Local Health District. } <br /> Exact Site Address SANTOS' RANCH. OT ��1� / own <br /> Owner's Name <br /> JAMES MOST Phone <br /> Address 29 EGRANTT,TNF Rl� City. <br /> Contractor's Name HENS S • DR II L3 __G(Il�ense# ) 3-._ <br /> Business Phone <br /> Contractor's Address 3525 a y,—_Mj0DEST0 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK). NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ +. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR I' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1 001 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL G <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> IX DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6I1 PV <br /> ❑ DOMESTiC/PUBLIC ❑ DRIVEN Gauge of Casing 160 1 WALL <br /> ❑ IRRIGATION M GRAVEL PACK Depth o1 Grout Seal <br /> ❑ CATHODIC PROTECTION Z ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information B— (n] <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ GRILLE <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> j PUMP REPLACEMENT: ❑ Stale Work Done <br /> PUMP REPAIR: ❑ State Work Done L� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing:"i certify that in the performanceof the work forwhich this permit <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 for which this <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 final ins ecfion. <br /> Signed X HENNINGS BROS. BY Date: <br /> (Draw Plot Plan on Reverse Si� ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Date <br /> Application Accepted By <br /> F <br /> Additional Comments: ,�1 nf� <br /> Phase 11 Grout Inspection Phase III of inspection ` )�! <br /> �B- Inspection I DatO � Inn By I�`� Date <br /> lk <br /> Fee IS Due: ❑ ANNUA LY •CO] PER UNIT PER SITE ❑ EACH ElJanuary i &Received By January 3 ❑ July 1 &ReceiveRdEMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ,I DATE DATE REMITTED AMOUNT <br /> FEE 4 43 <br /> LESS <br /> PRORATION <br /> PLUS <br /> j PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> � rI <br /> - ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 111 Received dy <br /> 1601 E.HAZEITON AVE.;P.O.Box 2049 STOCKTON, �9151 —_ <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />