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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 FOR OFFICE USE: APPLICATION jp/3 r Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 made in compliance with San Joaquin County Ordinance No. 1862'and the rules and regulations of the San Joaquin Local Health District. T— Exact Site Address 4,4'14 W. STONERIDGE DR. City/Town TRACY v� Owner's Name -DON COSE & ASSOCIATES Phone 836-0422 Address 1 9E 6th ST. city TRACY Contractor's Name FREITAS ELECTRIC License a X38471 Business Phone-2814 Contractor's Address 5362' W. "Gil ST. ' Emergency Phone SIA Is Certificate of Workman's Compensation Insurance on File With SJLHD? ` Yes XT No TYPE OF WORK (CHECK): NEW WELL DEEPEN 11RECONDITION0 DESTRUCTION WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION$) , PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tante _ Sewer Lines Pit Privy Sewage Disposal Field __ Cesspool/Seepage Pit Other property Line Private Domestic Well�_, Public Domestic Well _ INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ GABLE TOOL DIsL of Well Excavation M DOMESTIC/PRIVATE ❑ DRILLED .Dia. of Well Casing ❑ DOMESTIC/PUBLIC - ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Z ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �t- ❑ DISPOSAL ❑ OTHER . Other Information' ❑ GEOPHYSICAL ',Surface Seal Installed By: PUMP INSTALLAJION: _ • Contractor FREITAS ELECTRIC' •' ^ Type of Pump JET H.P. 1 tC: PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: f ❑ stale Work Done DESTRUCTION OF WELL: Well Diameter ( Approximate Depth - - Describe Material and'ProceAt 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:',I certify that in the performance of the work for which this permit is issu , I shall not employ any person in such manner as to.Ibecbme subject-lo workman's compensation laws of California:' Contra tor's hiring or sub�ontracting signature certiliea the fo lowing:"I certify that in the performance of the work for which this permit ils issued, I shall employ persons subject to workTan compensation laws of California:' 1 II fo rout l(tspe lion,prior to grouting and a final!!l Inspection. -T Signed X , filtle: _��_- ,t - Date: 1) ' 7 ' A. (Draw Clot Plan on Reverse Side) '�FFOR/D�EPI RTMENT Y SE ONLY \ PHASE I \ c ---�� f �y ApplicationlAccepted ByDate e 0�•. ' Additional �omments: A Phase II Grout Inspection Phase III Final Inspection �- / Inspection By. Date Inspection By Date y,/ �9 ti , Fee IS Due:'❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.EACH ❑ January t a Received By January 31 ❑ July 1 a Received By July 31 IREMIT I BASE EXPLANATI N all LINP RPMITTANCE 5 AMOUNT DUE CHECKED r DATE' DATE REMITTED ` AMOUNT FEE J v LESS ' - PRORATION( PLUS PENALTY OTHER ,r OTHER —7 b Z Received by Date Receipt No. Permit No. Issuance Dale Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.So.2009 STOCKTON,CA 95201