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ApplicationsWill Be ProcessedWhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> r., y PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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. 1882 and the rules and r ulations of the San Joaquin Local Health District. M_ <br /> Exact Site Address 2 341 S. Tsirelas_ Dr.—Lot 6 Santos YH City/Town <br /> Owner's Name J .D. Most Construction Phone 835-6921 <br /> Address 9 E . Grant-Line Ed . City c <br /> Contractor's Name Hennings Bros. Drilling Qicense# 290813 Business Phone 545-1185 94 <br /> Contractor,s Address 3 52 5 Pelanda1e Mod estD Emergency Ph one <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL I DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 100 t Sewer Lines Pit Privy <br /> Sewage Disposal Field loot Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL E] CABLE TOOL Dia. of Well Excavation <br /> 1 lit <br /> IX DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 FVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 Wall <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 50 t <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Cement <br /> ❑ DISPOSAL ❑ OTHER Other Information Slab-by owner <br /> ❑ GEOPHYSICAL Surface Seal Installed By: driller <br /> PUMP INSTALLATION: Contractor <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 LA <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 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 and a finalinstion. <br /> Signed X • Title:D -71 C41 Date: 7-23-82 <br /> (Draw lot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph se II rout Inspectiony Phase Ill Final Inspection <br /> Inspection By Date_1- Z�' �r Inspection By Date <br /> Fee Is Due: D 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 AMOUNT DUE CHECKED <br /> rr AMOUNT <br /> FEE 3 �P <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ;2- y 06'lto d <br /> Received by Oate Receipt No. ermit 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 />