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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` FOR OFFICE USE: LIGATION (For Non-Transferable,RevoCeble,SUspendable) - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora Pennitto construct and/or install thework herein described.This application is made in compliance with San JOagUln County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address F°renoh Camp Rd i mi le west of Fiw 99 aei , u Y__ City/Town D fi Side- 1 mi l e Owner's Name Joe raheet3 Phone 282-0843 ' Address 1201 ):.. n LDine Ave: I �, City- Stock on, Ca. Contractor's Name+,etu.i nay rOG 1'trlil ---12�� CQicense lf 2908 Business Phone_51-5-1185 I COntraOtor'SAddress 525 "elandales Modesto Emergency Phone )45-0271 ' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK(CHECK): NEW WELL1i1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ f ' REPLACEMENT❑ I .r DISTANCE TO NEAREST: Septic Tank iii. Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ' ❑ INDUSTRIAL ❑ CABLE TOOLDia ❑ . of Well Excavation n V1 DOMESTIC/PRIVATE .l ❑ DRILLED Dia. of Well Casing 11 ' ❑ DOMESTIC/PUBLIC - ❑ DRIVEN Gauge of Casing •iGA aQ IRRIGATION ° M GRAVEL PACK Depth of Grout Seal f7 ❑ CATHODIC PROTECTION 10 ROTARY Type of Grout P1 ' 13 DISPOSAL 13 OTHER Other Information - 1•11 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: rt Contractor - Type of Pump H.P. ' PUMP REPLACEMENT: Ii ❑ State Work Done PUMP REPAIR: ❑ State Work Done ' DESTRUCTION OF WELL: Well Diameter Approximate Depth I$ Describe Material and Procedure 1 I hereby certify that I have prepared 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. Homeowner or licensed adent'sslgnature certifies thefotlowing:"I certifythat in the performance of thework forwhichthis permit is issued, I shall not.er loy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 compensation laws of California." 1 will Call for a Grout Inspection prior to grouting and a fill inspection. 'Signed X Bennin>as Bros By' ` � 'Art IV / , Date: i+-1 -80 (Draw Plot Plan on Ell Sid ej ' FOR DEPARTMENT USE ONLY PHASEI � / ./r a ' Application Accepted By ' ,IG+f'.Additional Comments: • • f j` „� Date Phase If Grout Inspection r Phase[if Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Recall By January 31 ❑ July 1&Received By July 3t BASE EXPLANATION BILLING -RE MITTgNCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED l AMOUNT ' FEELESS ! PRORATION C,.i o.>• " , PLUS ' PENALTY OTHER .9 OTHER Receiqed by r D ( i` R¢Celpl No Permil No. Issuance Dat¢ Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.Hg2ElTON AVE.,P.O.Bev 2009 STOCNTON,CA 95201