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Applications Will Ba Processed When Submitted Properly Completed. Be Sure/ro Sign theApplication. 4 <br /> FOR OFFICE USE: / 'APPLICATION' _ '■ {. �C'��, <br /> . Non-Transferable, Revopable,Suspendable)- <br /> PUMP&WELL <br /> ENVIRONMENTAL HEp�TH/PERMIT <br /> (COMPLETE IN TRIPLICATE) till QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fqr a permi(to cpnstruct and/or install the work herein described.This application is <br /> made in compliance with San�loaq'uin County Ordinance No. 1862 ai d the rules.and regulations Of the San Joaquin Locals Health District. <br /> Exact Site Address Stoneridge Dr., Lot -1 atoneri�ge_$ub�_ CRy(Town _ <br /> Owner's Name Dale Co Pli'one �• — . <br /> Address px 12 6 r city Trary O <br /> Contractor's Name. Kenning SBTr. O,S� License#MA13—"' Business PhoneL-15-45_445 <br /> Contractor's Address' 3525 Pel and11 P' Mn(petn Emergency Phone _445–x7-4 p <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes,_}[_ No W <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN,❑ RECONDITION❑ - DESTRUCTION❑ <br /> WELL CHLORINATION ❑ ;..-'WELL ABANDONMy NT 011. OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ <br /> Sewage Disposal Field GCesspool/Seepage Pi; _, Other <br /> Property Line - Private Dpmestic Well - Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ 1 tt ` <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation -- <br /> 00 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ----16o—WALL <br /> 6I PVC <br /> 11DOMESTIC/PUBLIC Q DRIVEN. Gauge of Casing 1 0 WALL = <br /> ❑ IRRIGATION GRAVEL PACK Depth of Gr7ut.Si 50 t <br /> ❑ CATHODIC PROTECTION $I ROTARY Type of GroutCEMENT <br /> ❑ DISPOS ❑ OTHER Other Information ^SLAB–BY OWNER rS <br /> ❑ GEOpoy ICAL Surface Seal Installed By: DRILLER _ <br /> PUMP INST LATION: Contractor - — <br /> Type of Pump. „ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done . . <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth <br /> Describe Mater)at and Orocedure -- <br /> I hereby certify that I have prepared this appitybtion and that the work will be done in accordance with San Joaquin County i l <br /> ordinances,state laws, and rules and regulatio'niof the San Joaquin Local Health District.; <br /> Home owner or licensed agent's signature certifies!the following:"I certify that in theperformance of the work for which this permit �f <br /> Is issued, I shall not employ any personinsuch manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signatuiii certifies the following:"1 certify that in the performance of thework forwhich this <br /> permit IS issued, I shall gmploy persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Inspection prjor to grouting and a final Inspection. <br /> Signed X HENNINGS BBBS i' BY "� �Herse <br /> j;. ' - Date: 1 P-1 _$n ft• <br /> J 'i (Draw Plot Pl ., <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /•` _ <br /> Application Accepted By 1� 'Date /P <br /> Additional Comments: <br /> ase If GGrr/Qut Inspection 6.111 nal pection <br /> Inspection Bate_/1–'Z9–" InspectioDate V <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH P January 1 8 Received By January 31 ❑ July/ 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION 81LLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS - 7 <br /> PRORATION <br /> PLUS ., <br /> PENALTY <br /> t OTHER - <br /> OTHER <br /> Ma CSS/3 6866.f <br /> Received by at ' Receipt No. Permit No, issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />