Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) <br /> Zr: 4. PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District tora permit to construct and/or install the work herein described.This application is op <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Q <br /> Exact Site Address SANTOS RANCH EAST LOT 1 1E SANTOS CT. City/Town _ t <br /> Owner's Name James Most Phone 835-6921 <br /> Address city `r-,g CST <br /> Contractor's Name Hen1"'i_i ng q R-r_nG. License#2?QB13Business Phone 545-1-18.5 <br /> Contractor's Address _3<57_5ol andal a 2Modesth Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ g <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank }Cl t Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other j <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation tt <br /> M DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing " PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WA Tl __.... <br /> ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal t 1 0 <br /> ❑ CATHODIC PROTECTION IM ROTARY Type of Grout CE NT t <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAR_RY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i PUMP REPAIR: ❑ State Work Done_ – <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which 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 firing 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 inspec' n. <br /> Signed X HENNINGS BROS. BY "). - Date: LI--8-8o <br /> r (braw Plot P1an'on Reverse Side . <br /> i <br /> E <br /> OR DEPA76d <br /> NT USE ONLY <br /> PHASE I (Q <br /> Application Accepted By Date u <br /> Additional Comments: <br /> t1'tt'i out Inspections (� Phase inal Inspection <br /> Inspection By Date `w va I F <br /> Inspection By - Date — 5 r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received By Jan ary 31 ❑ July 1 R Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER m <br /> Cmc-- L'I� So G�13 O53 6t) <br /> I Received by -Date Receipt No. Permit No. Issuance Date Mailed y Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 <br />