Laserfiche WebLink
ApplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FFOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instail the work 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 16650 W. VON SOSTEN RD • _. City/Town _ TRACY <br /> Owner's Name . James Most Phone--835-6921 <br /> Address a rantline Rd. City Trac Q_- <br /> Contractor's Name HF'nnln S Br'O0* License# 0�-$�-1 - Business Phone 545-1185 <br /> Contractor's Address -1525 Pelandale Modesto Emergency Phone -0271 __ -J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XNo _ <br /> TYPE OF WORK (CHECK): NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Q PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1001 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation 1 et <br /> a DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 61` PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL- <br /> 11 IRRIGATION <br /> ALL11IRRIGATION GRAVEL PACK Depth of Grout Seal 50t <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB-BY QWR <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER T <br /> POMP INSTALLATION: Contractor <br /> 3 <br /> t Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 1,FJMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _.-. Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 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 Sart Joaquin Local Health District. <br /> Home owner 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> per mit 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 inspection. <br /> Signed X HENNINGS BROS. BY _ Titl SEC . -- Date: -16--81 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By_�. b� X1� � ---- Date 1 <br /> Additional Comments: <br /> ase Ii Grout Inspection se NI Fin 14ection <br /> Inspection By Date -tel 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS S <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a77G�7 � &7 �`z/i <br /> Received by Dote 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 2009 STOCKTON,CA 95201 <br />