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.Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) I <br /> WATER QUALITY `— ;C3 <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install thework 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. fi <br /> Exact Site Address x:182 W. STONERTDGE City/Town TRACY 114? <br /> Owner's Name DON CASE JI& ASSOCIATES Phone W <br /> Address 19 E. Eith ST. city TRACY <br /> Contractor's Name "FIREITAS ELECTRIC License# 3384.71 Business Phone 835-2814- <br /> Contractor's Address 5362 W. tif"" Sri'- Emergency Phone S/ A <br /> i <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 ❑ OTHER ❑ PUMP INSTALLATION 50 PUMP REPAIR❑ <br /> REPLACEMENT❑ I a1_ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other )ji <br /> I <br /> ProperEy Line Private Domestic Well Public Domestic Well <br /> INTENDED USEE] TYPE OF WELL <br /> I �` <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation , <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ^t� <br /> ❑ IRRIGATION i ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �I <br /> ❑ DISPOSAL ❑ OTHER Other Information TrA <br /> ❑ GEOPHYSICAL Surface Seal Installed By: � <br /> PUMP INSTALLATION: _Contractor ', i k;! <br /> TYPe of Pump JET f H.P. da <br /> PUMP REPLACEMENT: is ❑ State Work Done ? <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> I herebc#rtify that I have prepared this application and that the <br /> y w <br /> -, ork 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, Ifshall not employ any person in such manner as to become subject to woikman's-compensation laws of California." <br /> Contractorts hiring or sub-�contracting signature certifies the follo ing:"I certify that in the pe fo ante of the work forwhich this <br /> permit,is issued, I shall employ persons subject to workrria�! compensation laws of California." <br /> J <br /> I f ' a Grout In pection prior to grouting:nd a final inspection. cam, <br /> Signe II _ ' "1 Title: Date: 17 -2Z Z9 <br /> I` (Draw Plot Plan on Reverse Side) <br /> 4 <br /> FO EPA MENT US ONLY .. <br /> PHASE I <br /> cal <br /> Application Accepted By �' 4—/ Date <br /> Additional Comments: <br /> Phase II'Grout Inspection Phase 111 Final Inspection <br /> Inspectionaey �`M Date Inspection By Date a <br /> II <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE 0-EACH ❑ January 1,&-'R ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE- 'I EXPLANAT- N � BILLING�j _. 'REMITTANCE $ AMOUNTDUE CHECKED <br /> •"- •�DAZE� "' DATE REMITTED AMOUNT <br /> FEE <br /> LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY I� <br /> OTHER <br /> OTHER <br /> IIIIIID �9-14 33 9/1El75 <br /> Received by Date Ih Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COMES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 j` <br />