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Applications Will Be-PTdcessod When Submitted Pt operly Completed. Be Sure To Sign The Application. FOR OFFICE USAPPLICATION r Non-Transferable, Revocable,.Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PER"IT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance wittf San Joaquin Cougqtyy Ordinance N0.1862 and the rules and regulations of the San Joaquin Local Health District, Exact Site Address Rocky Point Cto L'D.t 32 Stoneridge Sub. Citylrown .-_. -- T- - ; — ---: Owners Name __ Dale CoSe _ !' Phone Address _T_ ,�,�- - oX" 2 - ,�_...=t cit.-Tracy-- Contractor's ity TraCyContractor's Name - Hennin 3 BIOS• __ License a 2Q0�_ Business Ph�on�eQ_ d45-Q2`�]._ - jp Contractor's Address 1525 Pe landal e Modesto Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHDn ' Yesi_�._ No TYPE OF WORK (CHECK)' NEW WELLM DEEPEN Q RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION P WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR Q REPLACEMENT❑ , DISTANCE TO NEAREST: Septic Tank Sewer Lines _ -_ Pit Privy Sewage pisposal Field 10 01 _ Cesspool/Seepage Pit -__ _ - Other ------ Property Line _ Private Domestic Well Public Domestic Well__. INTENDED USE TYPE OF WELL t ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of.Well Excavation 11116t' n PO DOMESTIC/PRIVATE ❑ DRILLED Die. of Well Casing 60t1WALLT 11DOMESTIC/PUBLIC El DRIVEN Gauge of Casing _ -1:1 IRRIGATION IRRIGATION M GRAVEL PACK Depth of Grout Seal 508 Q CATHODIC PROTECTION M ROTARY Type of Grout _—__ CEMENT ❑ DISPOSAL ❑ PTHER _ Other Information SLAB-BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER _ BUMP INSTALLATION: Contractor Type of Pomp _ H.P._T -- - PUMP REPLACEMENT: Q State Work pone- PUMP REPAIR: ❑ Slate Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have preQared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, Y Homeowner or licensed agent's signature certifies the following"lcertify that in.the performance of the work for which this permit 1 Is issued, 1 shall not employ edy pgrson.jn such manner as to kecome subject to workman's compensation laws of California." Contractors hiring orspbcontraeting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject'to workman's epmpengatlon laws of California." tA, I will pall fora Grout Inspection prior to grouting and a final inspection. O HENNINGS BRM BY y Date: 12-�I_—So_ Signed X (Prkw Plot Plan on Reverse Side) t FOR DEPARTMENT US; ONLY PHASE Application Accepted Byk9a_.4-�^� '_�=r - ._ _� _ Date Additional Comments:-- N , - - � —� - N Phase II Grout Inspection hose III Fin Inspection Inspection By ___.T_�- pate Inspection ey,� E"Date Fee If DUs: ❑ ANNUALLY ❑ PER UNIT f7 PER SITE ❑.EACH ❑ January b Repm� d By January 31 ❑ July 1 b Received By July 31 .'_'T_ '..-r-_ MI _ — RET_- _. BASE EXPLANATION BILLING FjEMiTTANCE S AMOUNT DUE CHECKED DATE PATE REMITTED AMOUNT FEE ��_ - - ' y3 LESS PRORATION -- PLUS PENALTY OTHER OTHER T _ - uecl rte PeaivoQ by a1 Rece�p}NONo. Perm,No. bsuancp Date Matlld Delivered APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE-,P.O.Boa 2009 STOCKTON.CA 95201