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Applications Will Be Processed When Submitted Properly Completed. tieSure ioa19n IncF%Fyn+..oa.— <br /> APPLICATION <br /> FOR OFFICE USE: 1 <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> r ENVIRONMENTAL. HEALTH PERMIT �T_ <br /> WATER QUALITY . <br /> (COMPLETE IN TRIPLICATE) <br /> n Local Health Districtfora permit to construct and/or install thework herein described.This application Is <br /> Application is hereby made to the San Joaqui <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San JgaAi �oca! Health District. <br /> Exact Site Address 23362 N. C IER City/Town <br /> Owner's Name J.D. MOST CONST' Phone <br /> Address 4 E• City <br /> Contractor's Name FREITAS ELECTRIC License# us'ness Phone <br /> I Contractor's Address Emergency Phone � <br /> `V <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION It PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> M DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ry ,'i ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> e ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor FREITAS ELECTRIC l/ <br /> Type of Pump ` H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 13 State Work Done <br /> [[ Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> j <br /> I hereby certify hat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat' laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or III censed agent's signature certifies the following:"1 certify that in the performance of theCwor-k for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workmah's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certi�fyat in.the--pertor,r agce:of thgO work forwhich this <br /> permit is issued; I shall employ persons subject to workman's compensation Laws of IIrforrna." <br /> I for a. ut Inspect' n prior to grouting and a final inspection ^2 <br /> S <br /> Title: <br /> ignedat <br /> (Draw Plot Plan on Reverse Side) <br /> F R D PARTM T USE ONLY <br /> PHASE I Date <br /> Application Acceptd By <br /> Y. <br /> Additional Co..mme ts: <br /> Phase 11 Grout Inspection hose III Fina! Inspecn <br /> t o <br /> Date Inspection By aft <br /> k inspectidI`- <br /> Fee Is Due: yAa.'NN ALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July &Received By July 31 <br /> ❑ <br /> REMIT <br /> BILLING <br /> } BILLING REMITTANCE AMOUNT DUE ,/'. CHECKED <br /> BASE EXPLANAT4ON DATE DATE REMITTED j.4 AMOUNT <br /> FEE <br /> LESS – <br /> PRORATION <br /> PLUS <br /> 1 PENALTY <br /> OTHER <br /> OTHER <br /> —"7`�`1-1X39 qtl <br /> Received by <br /> Date Receipt No, Permit No. Issuance Date Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />