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FOR OFFICE USE: ApplicationsWill Be Processed When Submitted Prope y Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <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 i <br /> made in compliance with Son Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 4067 W STOMIDGE DR. 5 <br /> Owner's Name DON COSE & ASSOCIATES City/Town TRACY <br /> Address E. ST. Phone 836^0422 <br /> Contractor's Name FREITAS ELECTRIC City TRA Y <br /> Contractor's Address I. . t1 G=� ST. License# 338471 BusingA Phone 835-2814 <br /> is Certificate of Workman's Compensation Insurance on File With SJLHDmergYesy Phone <br /> TYPE OF WORK (CHECK): No <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ <br /> NEW WELL❑ DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> REPLACEMENT❑ 11 OTHER ❑ PUMP INSTALLATION PUMP REPA IR❑ Q <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sew sge Disposal Field �; <br /> Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> ❑ INDUSTRIALIr TYPE OF WELL <br /> MC <br /> DOMESTIC/PRIVATE ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PUBLIC ❑ DRILLED Dia. of Well Casing <br /> ❑ IRRIGATION f ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL ❑ OTHER TYPe of Grout <br /> El GEOPHYSICAL <br /> Other Information <br /> PUMP INSTALLAT!_ON: (Surface Seal installed By: <br /> FRE <br /> _Contractor ITAS ELECTRIC. y <br /> „ Type of Pump JET <br /> PUMP REPLACEMENT: ❑ State Work Done H.P. <br /> PUMP REPAIR:( 11 I ❑ <br /> I I State Work Done I t <br /> DESTRUCTION OF WELL: Well Diameter <br /> i# Describe Material and Procedure Approximate Depth M, <br /> t7 ; <br /> I herebyr certify that I have prepared this application and that the work willL be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local'Health District. <br /> :al <br /> Horr(e,owner or licensed ag`ent's signature certifies the following: Lcertify that in the performance of the work forwhich this permit <br /> is issued, i shall not employ any person in such manner as to become subject tow orkman's compensation laws of California." <br /> Contraclor's hiring or sub-contracting signature certifies the followin <br /> permit;i i issued, I shall em l0 9 "I certify that in the performance of the work for which this <br /> p y persons subject to workman's compensation laws of California." t� <br /> Grout inspec ion prior to grouting--and a final inspection. p <br /> Signe "" <br /> �. <br /> Title: <br /> f {Draw Plot Plan on Reverse Side} �� Date., <br /> FORD PARTMEN USE ONLY <br /> PHASE I I� <br /> Application Accepted By <br /> Additional Comments: q 1 Date <br /> - Phase II Grout inspection _ <br /> Inspection By IM ,Phase III Final Inspection � <br /> Date Inspection By AA <br /> II�� __ _ Date 7 �. <br /> Fee IS Due: t—+~ANNUALLY ❑ PER UNIT PER SITE^ ❑ EACH ❑ January 1 &Received B January By 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATf.ON y i BILLING'_ ' REMITTANCE $ REMIT <br /> �OA7E DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> �Y <br /> OTHER <br /> OTHER <br /> Received by DateIN N �g' •f <br /> IILP Receipt No. Permit No. Issuance Date <br /> APPLICANT—RETURN ALL COPIES TO:Ig ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered <br /> II _ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />