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Applications WIII Be Processed When Submitted Properiy�Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> Non-Transferable,Revocable,Suspendable) <br /> ' PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER Q <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 S n Joaquin Count Ordinance No. 1862 and the rules and regulations of the'Sen aq in Local Health District, <br /> Exact Site Address 4097 W. STONERIDGE DR'. ' ' City/Town 'TRAY <br /> Owner's Name DON LOSE & ASSOCIATESPhone 836-0422 <br /> 19 Address I, - Oily TRACY <br /> I. <br /> Contractor's Name FREITAS ELECTRIC License# 338471 Busiss Phone 835-2814 <br /> ' ST <br /> ss <br /> Contractor's Addret Emergency Phone Sf A <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes X - No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN P RECONDITION❑ . DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑" OTHER P PUMP INSTALLATIONt PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy V <br /> 1 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL Q CABLE TOOL Dia.of Well Excavation <br /> QXDOMESTIC/PRIVATE Q DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC Q DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Q ROTARY Type of Grout <br /> ❑ DISPOSAL 1 ❑ OTHER Other Information <br /> Q GEOPHYSICAL Surfaae Seal Installed By: <br /> PUMP INSTALLATION: Contractor FREITAS ELECTRIC ' 1 , <br /> Type of Pump JET H.P. 1 <br /> PUMP REPLACEMENT: ❑ State-Work Done <br /> PUMP REPAIR: -I l] 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 V <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. �) <br /> Home owner or licensed agent's signature cartilies the following:"I certify that in the performance of 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 signaj:ure certifies the following:"i certify that in the performanceof the work forwhich this <br /> permit i}issued, I shall employ persons subject to workman's compensation laws of California." 0 <br /> 1 � <br /> t Grout Inspec on prior to grouting and a final inspection. -•{` <br /> Signe /�.... r Title: ERA ` Date: B-IS-�9 G <br /> (Draw Plot Plan�on Reverse Side) <br /> FOR PARTMEN -USE ONLY <br /> PHASE I q�U 9 <br /> Application Accepted By "` Date / / / <br /> Additional Cbmments: <br /> I Phase II Grout Inspection, hese III Final Inspection <br /> Inspecti¢n By Date Inspection By Date <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANy,1TIGN BILLING, REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —\! <br /> 9 9/Is/-7! <br /> `-7 <br /> Received by Date Receipt No. Permit No Nuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Be.2009 STOCKTON,CA 95201 <br />