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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL .� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f WATER QUALITY <br /> (COMPLETE IN IP KATE <br /> A li l is eto he oa uinLo�lHealthDistr d7r�permitte�tu a /or install the work herein described.This application is <br /> ma m 1 <br /> San lio> i rO7VSNo. 1 e'IFid�h� rule a ul o the San Joaquin Local Health District. <br /> Exact Stfe Addr s SANTOS RANCH� LOT ity/Town <br /> Owner's Name JAMESMOST Phone <br /> 2 E. GRANTLINE RD. City O <br /> Address � <br /> Contractor's Name BENNINGS BROS. License#2 0 '4 Business Phone_545-1185 � <br /> Contractor's Address 3 52 PELANDALE ' MODESTO Emergency Phone 51+5-0271 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes— No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ } <br /> DISTANCE TO NEAREST: Septic Tank 100 t 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 O <br /> ❑ INDUSTRIAL 1:1 CABLE TOOL Dia. of Well Excavation 1 lit <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6" PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL <br /> 13IRRIGATION til GRAVEL PACK Depth of Grout Seal 50S <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> CEMENT E <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB—BLOB ER <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done S <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter s 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 t <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 m <br /> is issued, l 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 <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 nal inspection. tt�.. l <br /> Signed X <br /> HENNINGS BROS. BY � SidDEC .- Date: 4-29 -80 � <br /> (Draw Plot Plan on Reve a e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date 7 B <br /> Additional Comments: <br /> Phase,li Gr4lut Inspection Phase fill FirlaInspection <br /> Inspection By Date I�1T Inspection By A Date 157 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 1 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 1 �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER <br /> Received by Dlate 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 20D9 STOCKTON,CA 9 I <br />