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ApplicationsWill Be Processed When Submit e+ Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: 'APPLICATION _ " � (For Non-Transferable, Revocable, Suspendable) / 7, �i ENVIRONMENTAL HEALTH PERMIT PUMP&WEtt (COMPLETE IN TRIPLICATE) Ii WATER QUALITY Application is hereby made tothe Sa'n 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 Joaquin Local Health District. Exact Site Address S tOae-rd4ge—])r o T._0t21_ St ope �,b Wity/Town Owner's Name Dale OOSe Phone Address T.O. BOX;! 26 City_T- ey _ O Contractor's Name I8AI1J rid S BPOS License#2908 j3 Business Phone 545—! 1 8� 1 Contractor's Address.,__ 3_ 2-J PCS an a,1�O[�e9t0 Emergency Phone Q j — Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No W TYPE OF WORK (CHECK): NEW WELL IM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ I� DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field_ 100 t... Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well �}{ INTENDED USE H TYPE OF WELL N ❑ INDUSTRIAL111 r.t it CABLE TOOL Dia. of Well Excavation PTT�I l DOMESTIC/PRIVATE II ❑ DRILLED Dia. of Well Casing 6" Y ❑ DOMESTIC/PUBLIC :; ❑ DRIVEN Gauge of Casing 160 WALL ❑ IRRIGATION I$ GRAVEL PACK Depth of Grout Seal Ot 11 CATHODIC PROTECTION ® ROTARY Type of Grout CEMENT ❑ DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER 13 GEOPHYSICAL Surface Seal Installed By: DRILLER PUMP INSTALLATION: I Contractor Type of Pump H.P. PUMP REPLACEM,�.NT: I © State Work Done PUMP REPAiR: i ❑ State Work Done DESTRUCTION OF WELL, h Well Diameter Approximate Depth Describe Material and Procedure f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, state laws, ad halve rules and regulations of the San Joaquin Local Health District. Home owner 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work for which 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 a final inspectionn Signed X HENNINGS BROS. BY Date: 12-1 -80 i� (Drav& Plot Pian on Reverse Side) II FOR DEPARTMENT USE ONLY ; i� - PHASEI h Application Accepted By_ `—�-; Y,Q� � Date Additional Comments: II T hase II G ut Inspection se III Fi I Inspection / Inspection B Date Inspection By !i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BASE II EXPLANATION BILLING REMITTANCE .$ REMIT f• II DATE DATE REMITTED AMOUNT DUE CHECKED - AMOUNT • 1, FEE D5�7 y3011 LESS II PRORATION PLUS PENALTY OTHER OTHER it 1.2-IS Y5 sem_r� �� > ,�. ��-d f: Received by D Receipt No Permit No. Issuance Date Mailed .Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201