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Applications Will Be Processed When Submitted.Properly Completed. Be Sure To Sign The Application. <br />�. FOR OFFICE USE: APPLICATIONk <br /> (For Non-Transferable, Revocable,Suspendable) <br /> MP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT PUMP <br /> } <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework.herein described,This application is J <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 15768 RANCHO RAMON <br /> City/Town TRACY <br /> Owner's Name J.D. MOST CONSTRUCTION Phone 835--6921 <br /> Address 49 E. 10 th ST. TRACY <br /> FREITAS ELECTRIC city <br /> Contractor's Name License# 338471 835-2814 <br /> Bu iness Phone <br /> Contractor's Address 5362 VST.11Glt ST• Emergency Phone S/A <br /> IS Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No ` <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER 11PUMP INSTALLATiTUN Cf PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �+ <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I qq 1 <br /> ❑ INDUSTRIAL �_ 1 —6i4' <br /> ❑ CABLE TOOL Dia. of Well'> xcavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia" of Well Casing <br /> ❑ DOMESTIC/PUBLIC �.,�.❑-DRIVEN--- '"°`—GFa`uge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea! �I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor FREITAS ELECTRIC <br />` Type of Pump SUBMERSIBLE H.P. 1 <br />'t PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxmafe.Depth <br /> i Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ` '°) +0 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance I 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 perform6ce of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California."I <br /> I wit call Grout Inspection prior to grouting Arid a final inspection. <br /> Signed sir E Title: Date: o <br /> —(Draw Plot Plan on Reverse Side) + <br /> OR 4 D PARTM T USE ONLY <br /> PHASE I `j <br /> Application Accepted By Date /y <br /> r <br /> Additional Comments: <br /> Phase II Grout Inspection Plla�se III Final Inspection t� <br /> r Inspection By Date Inspection By • let], Date ;;L 7 bl�- I <br />' Fee Is Due: ❑ ANNUALLY ❑ PER U IT PER SITE ❑EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> BILLING REMITTANCE $ - REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION t <br />' PLUS <br /> PENALTY <br /> E <br />° OTHER <br /> OTHER t - <br /> t —7 L <br /> 9l Igr7� f <br /> Received by Date w 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 95201 <br />