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a..,,... <br /> Applications Will Be Processed When Submitted ProperlyCompleted. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> inLocalHealthDistrictforapermittoconstructand/orinstallthework.herein described.This application Is <br /> Application is hereby made to the San Joaqu <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations the SaTRACYn Local Health District. <br /> 8975 �`AIROAKS RD. City/Town <br /> Exact Site Address 835-6921 <br /> J.D. MOST CONSTRUCTION Phone <br /> Owner's Name ,_ City TRACY i <br /> Address 49 E. 10th ST. 835- 81 <br /> , <br /> Contractor's NameMEITAS ELECTRIC License#338471 Business Phone <br /> 5362 W11 Gtl ST• Emergency Phone S1 L <br /> W.Contractor's Address X No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> RECONESTRUCTION <br /> TYPE OF WORK (CHECK): WELL`ABAELL❑NDONMENT ❑DEEPEN ❑ OTHER 13 ITl pU❑P INSTAL AT ON�❑ PUMP REPAIR❑ <br /> WELL CHLORINATION 11 <br /> REPLACEMENT El r Pit Priv Ni <br /> DISTANCE TO NEAREST:-_tSeptic Tank Sewer Lines y1 <br /> Other. <br /> sc <br /> Sewage Disposal Field Cesspool/Seepage Pit - <br /> Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE <br /> Dia. of Well Excavation <br /> ❑ INDUSTRIAL CABLE TOOL If <br /> I@ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casings <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing (� <br /> ❑ IRRIGATION ' ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ( ❑ OTHER Other Information <br /> 11 GEOPHYSICAL a Surface Seal Installed By: <br /> '` I <br /> ` PUMP INSTALLATION:- ) ,} € Contractor �EITAS ELECTRIC H P 1 <br /> } Type of Pump JET <br /> PUMP REPLACEMENT: i E] State Work Done '° u <br /> PUMP REPAIR: ❑ State Work Done _ <br /> _...__.� - _. ,.._. �. .-.,�T • ._ _.._. .w-�t>.__ k -� APp�oximate Depth_ <br /> DESTRUCTION OF WELL: Well Diameter y <br /> Describe Material and Procedure j <br /> I hereby certify that I have prepared this application and that the work will bye done in accordance with San Joaquin County t <br /> ordinances, state laws, and rules anYf regulations of the San Joaquin Local Health District. <br /> e of the rformanc <br /> Home owner or licensed agent's signaturecertifies the n such mannerasto becomtefy that in the subjecI to or kman's compensation attiionrk f laws of California."or which this I <br /> is issued, I shall not employ any person <br /> Contractor's hiring o, sub-contracting signature certifies the following:"I certify wstin the of CaliPorn�a.mance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation Iia <br /> I c Grout 1 �'7 <br /> ng and a final inspection. ! <br /> s Date: <br /> Title: <br /> Signe aw Plot Plan onReverse Side) <br /> ii i t <br /> � t ORD PAR7MENT USE-ON LIY ,.-• � � <br /> j PHASE il <br /> � ^t to <br /> Application Accepted By <br /> 4*01 1 r. <br /> Additional Comments: f Phase III Final.lnspection <br /> 1 Ph sell Grout Inspection <br /> 1 Date Inspection By ate <br /> Inspection By <br /> I.. <br /> i <br /> k <br /> Fee Is Due' ❑ ANNUALLY y ❑ PER UNIT ❑ PER SITE El ❑ Januar' 31 <br /> PER <br /> 1 &Received By January 31 July 1 &ReceiveREMITuly <br /> BILLING RFMiTTANCE AMOUNT DUE CHECKED <br /> $ASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I <br /> FEE I <br /> LESS <br /> i. <br /> 1 PRORATION k <br /> PLUS t <br /> PENALTY <br /> iA)s 'b <br /> r. � y..A rr...M <br /> OTHER <br /> OTHER,y ; <br /> —7�C� �1 -7 <br /> 1 f ~10LAPeermiOo. Issuance Date Mailed Delivered <br /> k Received by Date Receipt No. <br /> 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />