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'Applications Will Be Processed When Submitted Properly Colilpleted. Be Sure To Sign The Application. / ! FOR OFFICE USE: APPLICATION `G� 3d, I Non-Translerable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT' (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made td the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with Sagr,Ioaquin COUnty Ordinance No. 1862 and the,rules and regulations of the San Joaquin Local Health District. Exact Site Address_ OC - PDint, __Ja__IIOt 3D S_t_oxLII_Sllb6ity/Town Owners Name Dalt`3 COSe ` Phone' t M Address • O$ .32 _ City Tra nv —Ca. Contractor's Name Hennings Bros.- License N_2_998J �(_ Business Phone�L Contractor's Address 3525 Pelandalef Modesto_ Emergency PhoneIs Certificate of Workman's.Compensation lnsprance on File With SJLHD? ' Yes X.^ No TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION❑ DESTRUCT10N❑ 1J WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy' J- Sewage Disposal Field 100 Cesspool/Seepage Pit ' Other Property Line Private Domestic Well Public Domestic Well�_ O INTENDED USE - TYPE OF WELL ❑ INDUSTRIAL Q CABLE TOOL Dia. of Well Excavation 1 1 it ' �I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PC i ❑ DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing 16Q WALL ❑ IRRIGATION PC GRAVEL PACK Depth of Grout Seal K9f ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT ' V% ❑ DISPOSAL ❑ QTHER Other Information _ST AB_-,&Y_0NNER ❑ GEOPHYSICAL - Surface Seal Installed By:__DRILLER ) 1 . PUMP INSTALLATION: Contractor Type of Pump H.P. t at PUMP REPLACEMENT: Q State Work Done PUMP REPAJR: ❑ 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 t 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 arty 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 forwhich this permit is issued. I shall employ person;subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a It inspection. i Signed X B'NNINGS BRCS BY �� Date: 12��Q I . (Draw IGot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By_.(,cs.�—+3�-r� �2��st �\`v` _ Date_Z _� Additional Comments: se II Grout I apeetlon asalll Fin In ction Inspection B . Aate�.�—��' 90 Inspection By ate �Txz Fee Is Dile: ❑ ANNUALLY: ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 6 Received By January 31 ❑ July 1 a Received By July 31 BILLING REMITTANCE S REMIT BASE EXPLANATION 'AMOUNTOUE CHECKED , DATE DATE RE'M//ITTED AMOUNT FEE LESS PRORATION -+ PLUS - - ' PENALTY OTHER OTHER In 5�51.3d9e Reeeroed by Dare Receipt No. Perms No. Issuance Dale Mated Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201