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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) r <br /> ' <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a 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 17200 W. VON. SOSTEN RD. City/Town TRACY <br /> Owner's Name James MO StPhone 835-6921 <br /> Address 29 E. _Grantlin.e—R . City T-ra rev C4 <br /> Contractor's Name Hennings Bros License# 2908 _x_ Business Phone__..._.._%E� --1� <br /> Contractor's Address 35225 Pelindale. Mod.eStO Emergency Phone 545-0271 y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x - _ No <br /> TYPE OF WORK (CHECK): NEW WELL LX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ��_ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> e� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 1 t1 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL <br /> ❑ IRRIGATION M GRAVEL PACK Depth of Grout Seal 50 t <br /> ❑ CATHODIC PROTECTION IM ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUAP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter m Approximate Depth <br /> y ©', <br /> Describe Material and Procedure <br /> �r <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. <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 inspection. <br /> Signed X <br /> HENNINOS BROS . BY Title; Date: 1 -16-81 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PI?ASE I <br /> Application Accepted By J�-11-`y Date <br /> Additional Comments: <br /> Phase It Grout Inspection a Ill Fin Inspection <br /> Inspection By Date =/�F/ Inspection By Date <br /> ,Ja`c-p-„so-, . K4.d, /—/O --rl <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 AMOUNT DATE DATE REMITTED DUE GHSCKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r7 69 767 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />