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Applica►^- '-Jill Be Processed When Submitted Properly Completed. sesure Ioorgra . <br /> APPLICATION a <br /> F04 FF1C E,U.SE_ ,, Revocable, Suspendable) <br /> f - (For Non-Transter.-ble, pUMP&WELL 113 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> li <br /> WATER` UALITY I <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install theworkhereindescribed.Thisapplicationls <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 5512 HILDRETH LN-1 /$MI. EAST—0 0it 6+rj I <br /> I Phone <br /> GEORGE BIAGI <br /> Owner's Name � _ City <br /> Address 12 HILD TH _ <br />[ Contractor's Name <br /> HENNINGS BROS . License#2�08�-3-- Business Phone i <br /> I{ Contractor's Address 2�3 PELANDALE. MODES '0 Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes�� <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION <br /> ❑ <br /> WELL CHLORINATION C3 'WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ (n <br /> REPLACEMENT❑ t Pit Priv <br /> Sewer Lines y <br /> Sewage Disposal Field� <br /> DISTANCE TO NEAREST: Septic Tank -t Cool/Seepage Pit Other <br /> Cesspool/See f� <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL is <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 6Tr. PYr <br /> ❑ DRILLED Dia. of Well Casing 6n UjA T.T, <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> 13DOMESTIC/PUBLIC 1:1 DRIVEN <br /> 50 <br /> t <br /> ❑ IRRIGATION M GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION IR ROTARY Type of Grout B <br /> IM ILTE_ <br /> [I DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> { 13 GEOPHYSICAL <br /> t!i�� <br /> ~ <br /> � PUMP INSTALLATION: Contractor � H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I � Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> 1 <br /> I hereby certify that l 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 /> r Home owner or licensed agent's signature certifies the following:"IGcertify that in the performancem work for which this permit <br /> P <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compeennsation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"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 /> ,� Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Rev a Side) <br /> j FO DEPART ENT USE ONLY <br /> r <br /> l PHASE I Date <br /> Application Accepted By <br /> Additional Comments: a II Grout inspection P ase Final Inspection <br /> d"ld� <br /> Date Inspection By Date <br /> I Inspection Byr <br /> 4 L3 PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 &Received By July 31 <br /> F. Fee Is Due: I—] ANNUALLY ❑ PER UNIT REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> t <br /> FEE 1_0 <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> F OTHER #k <br /> t j.!OTHER <br /> 1.� C) -.�L'" — 1 issuance Date Mailed Delivered <br /> Date <br /> 1� Receipt No. Permit No. <br /> i Received 6y -. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES s <br />