Laserfiche WebLink
f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 9 <br /> (For Non-Translerable, Revocable, Suspendable) 1} <br /> PUMP&WELL <br /> ENVIRONA4ENTAL HEALTH PERMIT Q <br /> (COMPLETE IN TRIPLICATE) WA4QUALITY <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 r <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 16175 Mil eo Rd• City/Town _ R1TJOn <br /> Owner's Name Angelo Reba liati Phone 524- 967 <br /> Address `� 2024 Gulfstream Dr. city Modesto Ca . <br /> Contractor's Name Hennings Bros . _ License# 290813 Business Phone 545-1185 lrp <br /> Contractor's Address 3525 Pelandale Ave. �MO4 StEghergency Phone 545-0271 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes X No J <br /> TYPE OF WORK (CHECK): NEW WELL IM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 80, Sewer Lines Pit Privy <br /> Sewage Disposal Field 01 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 1:1 CABLE TOOL Dia. of Well Excavation <br /> 1 1 fit <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Err PVC <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing —160 WALL <br /> ❑ IRRIGATION IM GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION 14 ROTARY Type of Grout BENTONITE <br /> ❑ DISPOSAL ❑ OTHER Other Information SLAB-BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: i Contractor r <br /> Type of Pump CTIA H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: W ❑ State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �. <br /> 10 10l Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in acc rdance wit 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wI call for a Groutii9pection prior to grouting and?t1ijItial inspection. <br /> Signed X 44d4Date: <br /> (17kraw Plot Plan on R ;,We Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �y <br /> Application Accepted r- Date- 77 <br /> Additional Comments: <br /> Pkla 11 Grout Inspection P s 1111 Finalspection L <br /> Inspection By x <br /> Date+�O���./7 fInspection By Date <br /> r <br /> Fee is Due: 173 ANNUALLY ❑ PER UNIT 1:1 PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Gln L-- s d b► `7 1 9 1� -7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.',P.O.Box 2009 STOCKTON,CA 95 <br />