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Applications Will,Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> FOR OFFICE USE: APPLICATION - /a / 2-17 <br /> Non-Translerable,Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY )—XT �3 <br /> Application is hereby made to the San Joaquin Local Health District fore 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 X82 W fS`PON-FIRTT)GE ' City/Town TRp "Y } <br /> 0 <br /> Owner's Name DON COSE & ASSOCIATESPhone L' <br /> Address 9 E. 6th ST. - City TRACY. <br /> Contractor's Name FRPITAS ELECTRIC, Licenseff. 338471 Business Phone, 835-2814 <br /> Contractor's Address 5362 W_ DGlf ST- Emergency Phone �lA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ QTHER CI, PUMP INSTALLATION 0 PUMP REPAIR -� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ,_;T_� Sewer Lines Pit Privy <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 ❑ CABLE TOOL Dia. of Well Excavation <br /> 0 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 <br /> ❑ DISPOSAL I Q OTHER Other Information m, <br /> ❑ GEOPHYSICAL Surface Seal Installed�y: <br /> PUMP INSTALLATION: Contractior FREITAS ELECTRIC <br /> Type of P}tmp JET - H.P. 1 t7 <br /> PUMP REPLACEMENT: ❑ estate Work Done <br /> PUMP REPAIR: ❑ State Work Done a..� <br /> DESTRUCTION OF WELL: Well Diameter _,_, Approximate Depth <br /> i Describe Material and Procedule <br /> I hereby certify that 1 have prepared this application and lhat.the work will be done in accordance with San Joaquin County <br /> ordinancesr state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the followini;l certify that in the performance of the work for which this permit <br /> is issued. I:shall not employ any person IIn such manner as to become subject to workman's compensation laws of California:' <br /> Contractors hiring orsub-contracting signature certifies the lolldwing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons Subject to workman's compensation laws Of California." <br /> SigneI f a Grout In pec It n prior to grouting and a final Inspection. <br /> / Title: 122, Date: 21—ZZ 7C/ <br /> :(Draw Plot Plan on Reverse Side). . <br /> ' FO EPA MENT US ONLY <br /> PHASE )t <br /> Application Accepted By 11 Date <br /> 4� <br /> Additional Cc IT ' <br /> Phase II Grout Inspection Phase III Final Inspeelion <br /> Inspection By— gate Inspection By Date <br /> Fee Is Due: ❑'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING . ' REMITTANCE $1 aASE EXPLANAT N DATE PATE REMITTED AMOUNT DUE CHECKED <br /> ./ AMOUNT/ <br /> EEE <br /> 3 C/ <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.Soa]099 STOCKTON,CA 95201 <br />