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Applications:Will Be Processed When Submitted ProperlyCompletes. tse sure lo;Di9n , APPLICATION —� FOR OFFICE USE: II S For Non-Transferable, Revocable,Suspendable) pUMP&WELL i t ENVIRONMENTAL HEALTH PERMIT c� WATER QUALITY (COMPLETE IN TRIPLICATE) i . ri Joaquin LocaltHealth District for a permit to construct and/or install the work,herein described.This application is Application is hereby made to the Sa � made in compliance with San Joagtlhin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address. S, • CORRALr' HOLLOW R ) City/Town C 10 TR CY RO BAR�NCHI �I Phone Owner's Name lip city Address A Contractor's Name FREITASi� ELECTRIC License# 338471 Business Phone 835 2814 Contractor's Address 362 W II' GII "ST. III' Emergency Phone II i, insuranqce on File With SJLHD? Yes No Is Certificate of Workman's compensation TYPE Of WORK (CHECK): NEW WELL1. ❑ RECONDITIONED DESTRUCTION❑ I WELL CHLORINATION ❑ WELL ABANDQ_NMENT ❑ OTHER ❑ PUMP INSTALLATION IN PUMP REPAIR 13 i. �j REPLACEMENT❑ Pit Privy DISTANCE TO NEAREST: Septic Tank Sewer Lines Other G Sewage Disposal Field Cesspool/Seepage Pit Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation Q� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea! L b ❑ CATHODIC PROTECTION i ❑ ROTARY Type of Grout . I� \Other Information 11 DISPOSAL , I 11 OTHER. r- ) C ❑ GEOPHYSICAL ; I"' „ a% Surface Seal Installed By: i _ .FREITAS .ELECTRIC P 4 UMPyIN3T LLATION. Contractor -- '""`SUBNIERS3T H P 1-_ r11-----�,VII Type of Pump i PUMP REPLACEMENT, 11INT• j ! State Work Done ` PUMP REPAIR. ❑ State Work Done d� 1 Approximate Depth DESTRUCTION OF WELL: Well Diameter I Describe Material and Procedure that I'have prepared his application and that the work will be done i i accordance with San Joaquin County I hereby ce if y { c , . ordinances, state laws, and rules and regulations of the San Joaquin Local HealthDistrict, 11. Home owns or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, l Shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or!Isub-contractinglsignature certifies the following:"I certify that f th performance of the work for which this j permit is issfued, I shall employ persons subject to workman's compensation laws of C lifornia." I! !j I will I a Grout;lns eclion prior to grouting and a final inspection. _ l Title: Date: E Signefl _ �� (Draw Plot Plan on Reverse Side) ''41,j `' :I I FOR PARTM NT USE ONLY PHASE 1' Date Application Acce 4eday�I j Ir Additional Comments: se 11 Grout In Ph, se Phase fll Final Inspection a Inspection By CDate Inspection By (Date I July 1 &Received By July 31 Fee IS Due' El ANNUALLY ❑ PER UNITi El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ r! REMIT 'i�' I1ri BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT f ,I— IIII FEE LESS fI I PRORATION I PLUS Ill XI PENALTY I OTHER OTHER r cm issuance Date Mailed Delivered Received by ate Receipt No. Permit No- r. Da1601 E.HAZELTON AYE P.O.Boi 2009 STOCKTON,CA 95201 APPLICANT—RETURN ALL�i OPIES TO: ENVIRONMENTAL—HEALTH PERMIT/SERVICES �.