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Applications Will Be Processed Property Completed. Be Sure o Sign The Application. ed When Sut * 1 FOR OFFICE USE: `• APPLICATION !O/ ✓ , Non-Transferable, Revocable,Suspendable) PUMP&WELL ow rwoy/� ENVIRONMENTAL HEALTH PERMIT (CO AT WATER QUALITY ' 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 made in compliance with SAn`Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Lot #31 Stoner-.ge-S-Ub-�'1 on . CityrTown 41.$9-R.ocky.Point rt, — Owner's Name, Dori LOSS & Assoc. Phone Address P.O. , Box 126 City Trn cw ' p Contractor's Name Hennings Bros♦ _ License p 081 'i Business Phone—��sr,5 Contractors Address _3525 Pelandale, Modesto Emergency PhoneIs Certificate of Workman's Compensation Insurance on File With SJLHO? Yes X No ) TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ - OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ C REPLACEMENT❑ N DISTANCE TO NEAREST: Septic Tank 1001+ 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 O CABLE TOOL Dia. of Well Excavation.^ 11 It _ * DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing , Or PVC ❑ DOMESTIC/PUBLIC ❑ PRIVEN Gauge of Casing 160 WALL ❑ IRRIGATION Xl GRAVEL PACK Depth of Grout Seal 50, ❑ CATHODIC PROTECTION IN ROTARY Type of Grout - CEMENT ❑ DISPOSAL Q OTHER Other Information_SI,A B_—nBY__0MNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER a PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: q State Work Done PUMP REPAIR: ❑ State Work Done _ DESTRUCTION OF WELL: Well Diameter. Approximate Depth Describe Material and Procedure 3 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring orsub-contrabting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior tp.grouting and a final inspect. Signed X HENNINGS BRO5 . BY '76%?(et L[ M.!�C' a SEC . Date: 5-15-80 ( raw Plot Plan ori Reverse Side) • FO EPARTMENT USE ONLY PHASE I �//6 /�Af�5 Application Accepted ey Date "-'t"-' Additional Comments: +ff^�tf- Ph a IJ ut Inspection S i7l�o Phase III final Inspection Inspection Byt./� Date Inspection ByDate Fee Is Due: ❑ ANNUALLY •LJ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE t $ e ,3 LESS PRORATION PLUS PENALTY OTHER - OTHER Irl s �� So 33/ 0 os33`/ Received by Dale Receipt No. Permit No. Issuance Date MailedETON, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.9o.2009 ST CA 95101