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--I Olivna wm oerrocessedWhenSubmitted Properly Completed. Be Sure To Sign The Application. r <br /> rFOROFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install thework 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 16714 W. VON SOSTEN RD a City/Town <br /> RAS-Y <br /> Owner's Name James Most 8�5-6g21 <br /> Address 2 E . Grantline Rd, City Phone Tra e <br /> Contractor's Name Hennin S Bros o License# 2908_1_1 Business Phone <br /> Contractor's Address _ 3525 Pelane'l-i Mac3e5t0 -1 18 <br /> Emergency Phone }-I 02 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL RE DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1001 Sewer Lines .__ Pit Privy <br /> 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 lit <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing 6" PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - 160 WALL <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB-BY OWNER <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor �— <br /> Surface Seal installed By: DRILLER <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done -F <br /> •PIfMP REPAIR: ❑ <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 1 <br /> Describe Material and Procedure Approximate Depth ! <br /> 4 <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 /> 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." <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 inspe tion. <br /> Signed X HENNINGS BROS. BY �l.7�Sid <br /> SEC . Date: 1 -16-81 <br /> (Draw Plot Plan on Revers <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> ase II Grout Inspection ase III Fin Inspection <br /> Inspection By ate—3 36-Y,/ Inspection By Date -3/-€l <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 �3JJJffflll <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a X77 � 97� _&,7 <br /> Received by ateI Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA 95201 <br />