Laserfiche WebLink
Applications Will Be Processed When Submitted Properly•Completed:Be Sure T6 Sign The Application. <br /> FOR OFFICE USE: APPLICATION . <br /> (For Non-Transferable, Re ocable;'Suspendable) <br /> PUMP&WE=LL <br /> ENVIRONMENTAL HEALTH PERMIT — - <br /> .. J - <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY f"G'T= -2- <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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> r <br /> Exact Site Address 15845 RANCHO RAMON city/Town TRACY <br /> ' Owner's Name J D MOST CONSTRUCTION835-6921 <br /> Address E 10th ST Phone <br /> City TRACY <br /> Contractor's Name FREITAS ELECTRIC License# 338471 Business Phone 835-2814 <br /> t Contractor's Address _5362 W.ttGtt ST. Emergency Phone S A <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br />! WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal FieldCesspool/,Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL_ Dia. of Well Excavation 11 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 13 GRAVEL PACK Depth of Grout Seal <br /> { <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 JET H.P. 1 <br /> PUMP REPLACEMENT: 13 state Work Done I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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.-, <br /> �. <br /> i <br /> 9 q •� i <br /> Homeowner or licensed agent's signature g g ure cerUfles the following:"I certify that in the performance ofthe 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 call or a Grout Inspection prior to grouting and a final inspection. <br /> Sig .,®-. Title: �1g'c{,1A - Date: . <br /> 4 - <br /> i � `. -%� i (Draw Plot Plaa n on Reverse Side) I '1 <br /> FO DEPART ENT USE ONLY { <br /> PHASE I •, { <br /> Application Accepted By Date Y <br /> Additional Comments: <br /> Phase Il Grout Inspection /'-P i se III Final Inspection <br /> Inspection By t Date Inspection By G r Date a <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMDUN7 DUE CHECKED <br /> # AMOUNT <br /> / t <br /> FEE 4W <br /> 4/13 LI j <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `7 q <br /> Received by - + Dale+ ' 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 />