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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FORS FFICE-USE: APPLICATION <br /> -� (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEAITH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or installthework herein described.This application is <br /> made in compliance with San.Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address Stonerid e Dr. Lot Stoneridge u�O_ City/Town <br /> i <br /> Owner's Name Dale COSe Phone <br /> Address OX 2 City Tra cv 0 <br /> Contractor's Name Hennings Bros license 42C)0.8J — Business Phone <br /> Contractor's Address 352 5 Pelanda 1e Emergency 545-0-271 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes__ No 0 <br /> TYPE OF WORK (CHECK): NEW WELL30 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Cl <br /> REPLACEMENT❑ <br /> I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 1001 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well - Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> t ❑ 11 lit <br /> INDUSTRIAL 1:1CABLE TOOL Dia. of Well Excavation <br /> s DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 11 PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 0 WALL <br /> ❑ IRRIGATION 10 GRAVEL PACK Depth of Grout Seal 501 <br /> r ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout CEMENT <br /> ❑ OTHER Other Information SLAB-BY OWNER <br /> 1:1 alsPosA DRILLER <br /> ❑ GEOPHYYICAL Surface Seal installed By: <br /> PUMP INST,ALATION: Contractor <br /> b Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ' ' ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I 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 /> I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit QS <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 1� <br /> h 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 adnal ins ection. - - Y <br /> signed X HENNINGS MOSS BY Date: 12-1 -8o <br /> t (Draw Plot Plan on R erse Si e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 �- <br /> Application Accepted By T �, C "l��-� J Date _1-2 <br /> Additional Comments: <br /> ase 11 Gr ut Inspection se 111 'nal pection <br /> i. Inspection By � ate��-�9-FO Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT = <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ` <br /> �FE3s� 413SORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> {+,h Received,by Dat Receipt No, Permit No, -issuance.Date Mailed Delivered ,d .r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201' r <br />