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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) - PUMP 9-WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY "' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew ork.hereindescribed.Thisapplicationis made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 4150 W. ROCKY POINT COURT City/Town TRACY - t Owner's Name DON LOSE & ASSOCIATES Phone 836-0422 Address - Lrt 6th ST City TRACY Contractor's Name FREITAS'ELECTRIC =License# 338471 Business Phone 835-2814 y Contractor's Address 5362 W. "G" ST. Emergency Phone SIA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes K No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION® PUMP REPAIR❑ REPLACEMENT E] l 4_,` 0 DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well C� INTENDED USE TYPE OF WELL ❑ INDUSTRIAL d ❑ CABLE TOOL Dia. of Well Excavation 11DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Q ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROT CTION ❑ ROTARY Type of Grout l a ! 7r C3 DISPOSAL E] OTHER Other Information ► 1:1 GEOPHYSICAL I .. _. �,.__ --- " -- - �-"•-�•-- Surface Seal Installed By: ~CA PUMP INSTALLATION: Contractor FREITAS ELECTRIC Ii Type of Pump E H.P. �f PUMP REPLACEMENT: ❑ State Work Done a F PUMP REPAIR: ❑ State Work Done ' DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will"be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquiniocal Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit t is issued, !i shall not employ any person in such manner as to-become subject to workman's compensation laws of California." r ti I Contr`actor's hiring or sub-contracting signature certifies the,follouring:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workr4an's compensation laws of California.' a I wil call fo rout Inbpe tion prior to grouting and a finalllnspection. t � --7 t Signed r _x _s' Title: Date: ��--� 1- y (Draw Plot Plan'on Reverse Side) F RyDEPRTMENT U ONLY I PHASE I ,1 I Application Accepted By Date f r Additional Comments: ` Phase II Grout Inspection ( Phase III Final Inspectio Inspectiony Date Inspection By!M 4 Date - 7 F Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATI BILLING REMITTANCE $ AMOUNT DUE CHECKED - P DATE DATE REMiTTFD AMOUNT FEE LESS PRORATION I _ - i PLUS J y PENALTY r r OTHER OTHER —7g�� G/1�f7q Received by Date Receipt No. Permit No. issuance Date Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.en■2009 STOCKTON,CA 95201 '