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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. FOR OFFICE USE: 1 APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT o (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework,herein described.This application is _J 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 SANTOS RANCH EAST LOT GRUNAUER RD. City/Town Owner's Name James Most F PhoneL� Address 29 E Grantline Rd . city Tra Cy Contractor's Name Hienm n S BI'O'S• License# 290513 Business Phone,545-1185 4, --0221 Contractor's Address � 25 Pelariaale�ModeStfl Emergency Phone _ -� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No TYPE OF WORK (CHECK): NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines Pit Privy r Sewage Disposal f=ield Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation_6" PVC M DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1060 WALL 11 IRRIGATION GRAVEL PACK Depth of Grout Seal 50 t ` 11CATHODIC PROTECTION ROTARY Type of Grout CEMENT ❑ DISPOSAL ❑ OTHER Other Information SLAB BY OWNER 13 GEOPHYSICAL # Surface Seal Installed By: DRILLER PUMP INSTALLATION: Contractor fr Type of Pump H.P. {{ dl PUMP REPLACEMENT: ❑ State Work Done 1 4� PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County G ordinances, state laws, and 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 inspect' I Signed X _ BENNINGS BROS. BY ��11IaLP�G�rtfi>� Date: -5-80 1 (Dr"Plot Plan on Reverse Side) FOR DEPART NT USE ONLY ~' i PHASE Application Accepted By Date Additional Comments: �Final hawse rout Inspectiori Phase IIIspections..a u r r Inspection By Date % Inspection By Date S 6 O Fee IS Due: ❑ ANNUALLY PER UNIT ER S$TE ❑ EACH ❑ January 1 &Received 8y January 31 '❑ July 1 &Received By July 31_ REMIT BASE EXPLANATION BILLING - REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE I LESS PRORATION f PLUS PENALTY - .- OTHER r OTHER 5 6 �{ k(ed Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.ROK 20U9 STOCKTON,GA 45201