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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION .. �_. (For Non-Transierable, Revocable, Suspendable) ' ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY 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 made in compliance with San Joaquin County Ordinance No, 1862 and the rules and regulations of the San Joauin Local Health District. Exact Site Address 8�U " S a SEXTON RI}a �2M�• SOUTH OF Y IrtPTftn �AIEST SIDE Owner's Name RAY SILBUR Phone 838-2817 Address 18342 S. SEXTON RD. City ESCALON Contractor's Name BENNINGS BROS. DRILLING CQoense# 290813 Business Phoned 1 $ Contractor's Address .3 525 PELANDALE D MODESTO Emergency Phone 4 —0271 I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 6 0 1 iw— 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 2611 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - 1611 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing JGA IRRIGATION 0 GRAVEL PACK Depth of Grout Seal None ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout none ❑ DISPOSAL M OTHER REVERSE ROTAF&er Information SLAB— By owner ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor .,C Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done .p DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 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:"I 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 of sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich 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 al inspection. SignedX _ AENNINGS BROS. BY314-80 -�• --- — -- Date: (Draw Plot Plan on Re rse 6de) FOR DEPARTM IT USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase H Grout Inspection P ase III Final Inspection Inspection By Date Inspection By Date RD Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Re eived By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED A 9ATE -DATE REMITTED AMOUNT FEEAL LESS PRORATION PLUS PENALTY OTHER OTHER 0Z7 Reeived by Date( Receipt No. Permit No. ssuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 01