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Applications Will Be Processed When Submitted Properlycompieieo. oe aura rU01411 r _..Nr•��• <br /> FOR OFFICE USE: y APPLICATION <br /> (For Non-Trahsierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> (COMPLETE IN TRIPLICATE) r�� <br /> TER QUALITY f <br /> Application is hereby madet;� C qu iivl �i tr a permit to construct and/or install thework herein described,This application i's <br /> shade in compliance with Sa J aquin ounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address KOSTER RD.SMI. SOUTH OF HWY 1 2 EAST C5tPFWR <br /> THELMA BENNETT Phone _ 836-1119 <br /> Owner's Name <br /> Address 1603 LINCOLN NO. 1 city TRACY <br /> ,ontractor's Name HENNINGS BROS• License# 29081 3 Business Phone <br /> Contractor's Address 3 2 FELANDALE , MODESTO Emergency Phone -02 1 <br /> 7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK(CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O? <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 150 t Sewer Lines _ Pit Privy p7� <br /> Sewage Disposal Field Cesspool/Seepage Pit 10 t+ Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - -ln <br /> It DOMESTIC/PRIVATE El DRILLED Dia. of Well Casing Est PSC 1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL <br /> GRAVEL PACK Depth of Grout Seal 0 t <br /> El IRRIGATION <br /> 11 CATHODIC PROTECTION IN ROTARY Type of Grout BENTONITE <br /> ❑ OTHER Other Information SLAB—BY OWNER <br /> © DISPOSAL DRILLER <br /> E] GEOPHYSICAL Surface Seal Installed By: <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 final inspection. <br /> Signed X HENNINGS BROS. BY fcIl SEC. Date: 9-9-80 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /��Q/j'� g�] <br /> Application Accepted By fate <br /> Additional Comments: <br /> t=Smpectlon YL <br /> Phase III Final Inspection <br /> Inspection By Date_ Inspection By Date <br /> F Fee IS Due: 11 ANNUALLY ❑ PER UNIT El PER SITE E3 EACH ❑ January 1 &Received 8y.kanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE �R{-EiM�ITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ate Receipt No. Permit No. I suance Date Mailed Delivered <br /> 1641 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />