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- Applications Will Be Processed When Submitted Properly Completed. BeSureTosign IneAppucauvii. <br /> EFOROFFICEUSE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) pUMp&WFLL <br /> w <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fore permitto construct and/or install the work herein described.This application Is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sar JooaaquY Local Health District. <br /> 2 254 SQ. CURRIER DR. City/Town TRA <br /> Exact Site Address 835-6921 <br /> I <br /> i owner's Name J. MOST CONSTRUCTION Phone TRACY <br /> Address <br /> E 10th ST. City 835_2814 <br /> Contractor's Name FREITAS . ELECTRIC License# 33847 Business Phone <br /> ;2 W It 01: ST, Emergency Phone +� <br /> Contractor's Address • <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No I <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT 11 OTHER 11PUMP INSTALLATIONS PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> t Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11CABLE TOOL Dia, of Well Excavation <br /> 11 INDUSTRIAL <br /> JE) DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge,of Casing Y� <br /> ❑ IRRIGATION ❑ GRAVEL PACK i Depth of Grout Seal <br /> r T e of Grout 'W <br /> 13 CATHODIC PROTECTION 13 ROTARY YP Iw <br /> ❑ DISPOSAL 11 OTHER <br /> i Other information._ ` <br /> ❑ GEOPHYSICAL ^ Surface Seal Installed By: 1 <br /> PUMP INSTALLATION Contractor BREI IRAS ELECTRIC <br /> Type of Pump JET`i fly1 <br /> PUMP REPLACEMENTf ❑ State Work Done I kyr <br /> F 11 State Work Doe <br /> PUMP REPAIR: a <br /> Well Diameter I Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I hereby.certify that I have prepared this application and <br /> that the work will be done in accordance with San Joaquin County <br /> ordinanc4l' state laws, and rules and regulations of the San Joaquin Local Health District. 1 <br /> (dome owner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for which this permit <br /> is issued, l sthalh not employ any parson 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 f California."rformance of[he work forwhich this <br /> permit-,tis issued, I shah employ per subject to workman's compensation laws of Califo <br /> i n i <br /> I I-willallo rout nspeclion prior to grouting and�a final.inspeCtiond �� _ <br /> Signed r Title: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FO EPA TMENT USE ONLY <br /> PHASE II /I <br /> Rate <br /> r Application Ac epted By <br /> 1 /44 <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase 111 Final Inspection <br /> Date <br /> Fee <br /> Inspection By Date Q <br /> Inspection iBy <br /> Fee Is Due: ❑ �NNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received Ry January ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATI N DATE DATE REMITTED AMOUNT <br /> j <br /> 1 FEE <br /> LESS <br /> PRORATION <br /> IL PLUS <br /> { PENALTY <br /> OTHER <br /> ' OTHER <br /> k_ <br /> Date - .�Receipt No. Permit No. Issuance Date Mailed ,Delivere <br /> Received by d <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH`PERMITISERViGES - - - - <br />