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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: a APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) 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 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 /> Exact Site Address 1992.2 . MADRID_ City/Town <br /> TRACY <br /> Owner's Name Phone 83 —6921 <br /> Address E. 10th ST. City TRACI <br /> Contractor's Name FREITAS ELECTRIC" License#338471 BLtsiness Phone 835-- 8 4 <br /> Contractor's Address 5362 W_ "13" ST. Emergency Phone A <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 IM PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field ` Cesspool/Seepage Pit Other y <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation i <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 3 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By; <br /> PUMP INSTALLATION: Contractor -FREITAS ELECTRIC 41 <br /> Type of Pump STET H.P. 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - t n Approximate Depth 1.J <br /> Describe Material and Procedure { <br /> I herebly 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, I <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, 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 4ollowing::I certify that in the perlformance of the work for which this <br /> per mit'is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Z7 <br /> illor Groul,,nspectian prior to grouting Arid a.-final inspection: f� <br /> 1 ) ; <br /> Signed Title: Date: S—I q ?9 <br /> I (Draw Plot Plan on Reverse Side) <br /> j <br /> OR EPART ENT USE ONLY <br /> PHASE! kk! p <br /> Application/accepted By Date ?/ <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection �f ' <br /> Inspection By Date Inspection By ate <br /> j <br /> Fee Is Due: Q ANNUALLY ❑ PER UNIT to PER SITE IJ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t <br /> BILLING REMITTANCE REMiT BASE EXPLANATION AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 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 />