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Applications Will Be Processed When Submitted ProperlyCompleted. Be SureToSignTneAppllcanon. <br /> FOR OFFICE USE: APPLICATION <br /> y (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 1 & 82 VON OSTEN RD e City/Town <br /> TRACY <br /> Owner's Name James Most Phone-835-6921 <br /> Address 29 t tl ne Rd. City Tracy – <br /> Contractor's Name Hennin S Bros• License# 29081 _�_ Business Phone____ 4 –11 <br /> Contractor's Address _152_5_Le_l Tl__._.___d Modesto Emergency Phone 545-0271 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No _J <br /> TYPE OF WORK (CHECK): NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines fit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 11 t1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL_ Dia. of Well Excavation— <br /> 01 <br /> PVC <br /> I1 DOMESTIC/PRIVATE E] DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — 160 WALL <br /> ElIRRIGATION IX GRAVEL PACK Depth of Grout Seat 501 <br /> ❑ CATHODIC PROTECTION IX ROTARY Type of Grout ' CEMENT <br /> ❑ DISPOSAL - ❑ OTHER Other Information SLAB—BY OWNER <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PQlAP 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 /> Homeowner or licensed agent's signature certifies the foliowing:"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 /> 1 will call for a Grout Inspection prior to grouting and a final pection. <br /> Signed X HE NTNG BROS. BY ' I SE' C• Date: - 1 6-81 <br /> (Draw Plot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> se II Gr Inspection P se III Fin In tion <br /> Inspection By -Date_ �/J 3&F/ Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BREMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dat6 Receipt No. Permit No. Issuance Date Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 <br />