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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> (COMPLETE IN TRIPLICATE)' ;Z3Gf(.S S- event,,o j-p,�_- TER QUALITY Zai 3sa_ice <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. s <br /> Exact Site Address UNIT 1 LOT 7y SANTOS RANCH GRUNAUEH RI y/Town <br /> Owner's Name JAMES MOSTPhone $35-6021 <br /> Address __ �9 E . GRANTLINE RD . City TRACY <br /> Contractor's Name HENNINGS BROS. DRILLING Cil)oense# 29081B Business Phone 5`r1185 <br /> Contractor's Address3-525_ PELANDALE AVE. I MOD. Emergency Phone 545-0271 j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION-,[--] PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1 001 Sewer Lines Pit Privy <br /> Sewage Disposal Field. Cesspool%Seepage Pit Other I <br /> Property Line Private Domestic Well Public Domestic Well Ih <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 1 n <br /> 1V DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 61t PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN- Gauge of Casing 160 WALL <br /> ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL t ❑ OTHER Other Information SLAB—BY UNNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION-OF WELL: Well Diameter Approximate Depth 9 <br /> Describe Material and Procedure <br /> 1� <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. i <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 grguting and a final inpect' � <br /> Signed X HENNINGS BROS .. BY 1ze <br /> Date: 11 —28-79 T. <br /> aw Plot Plan on Reverse Side) <br /> I <br /> FOR EPART ENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> rPhase 11 Grout Inspection Ph III Final Inspectio <br /> Inspection By L Date Z Inspection By Date�Z 7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT OCPER 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 /> A. AMOUNT <br /> FEE 3 <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 5 <br /> OTHER <br /> OTHER <br /> o .o <br /> -7 --7-t-1­:l,_%9 11��9i7q <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />