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ApplicationsWill BeProcessedWhenSubmitted ProperlyCompleted. BeSureToSignTheApplication <br /> FOR OFFICE USE: APPLICATION - <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 1!F <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exac,- Site HC1Qi2 sS.Tsi.rela s Rd ,- LOt 107 Santos City/Town <br /> Owner's Name J• D . Most Phone <br /> Address 29 E . Grantline Ed . City <br /> Contractor's Name Hennings Bros. License# 29Q81-3— Business Phone 545-1185 <br /> Contractor's Address 525 Peland&lelMod esto Emergency Phone E <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK (CHECK): NEW WELLKI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 100 1 Sewer Lines Pit Privy <br /> Sewage Disposal Field 100' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ 1 it <br /> 11 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6" PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 hn WAT L <br /> ❑ IRRIGATION KI GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION KI ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB--BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER 9_ <br /> PUMP INSTALLATION: Contractor .1l <br /> 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 /> 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 /> Homeowner 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 /> 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 a final inspection. <br /> Signed X HENNTNGS BROS . DRILLING CO. $ I le; BY� �p Date: _JULY 2951 9 2 <br /> (Draw Plot Plan on Reverse Si e) <br /> it <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By�� - __ Date �_���� <br /> Additional Comments: <br /> ha II Grout Inspection r� Phas III Final Inspection <br /> Inspection By Date ! 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE .4 43 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1-f C) <br /> Received by oate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />