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pipmarronsWul tieProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFF.ICE USE: APPLICATION <br /> ?, — (For Non-Transferible, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <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 -16676 W. VON SOSTEN RD. City/Town TRA(.,y - <br /> Owner's Name James Most Phone_ 8 —6921 <br /> Address 29 E . Grantline Rd. <br /> _, City_ I'ra C _ <br /> Contractor's Name Hennin S Bros . License#-290 Business Phone <br /> Contractor's Address .3S2 Pelanda 1 a_ MO � — <br /> f�ES't0 Emergoncy Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes` T No �-- <br /> TYPE OF WORK (CHECK): NEW WELL Gffi DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEJV,r NT❑ <br /> DISTANCE TO NEAREST: Septic Tank 10011 Sewer Lines Pit Privy <br /> o Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 <br /> XI DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Gtr PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 L <br /> ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION 10 ROTARY Type of Grout CEMENT w <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PIMP REPAIR: ❑ State Work Done ! <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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. f <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." r <br /> Contractor's hiring or sub-contracting signature certifies the following:"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. I <br /> Signed X HENNINGS BROS .— BY ­ Title: SEC.Date: 1 -16-81 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By — Date <br /> Additional Comments: <br /> Pli Grou nspection ase ill Fi I I pection <br /> Inspection By� ate . 9— Gam` Inspection B nate _�/G—Jr <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 3 Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M a4 7 <br /> Received by bate Receipt No. Permit No, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVIIssuance Date Mailed Delivered <br /> CES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 <br />