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Applications Will BeProcessed When.Submitted Properly Completed. Be Sure To Sign The Application. {� I FOR OFFICE USE: APPLICATION + . �`� . I Ir 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 fore permit to construct and/or install the work herein described.This application is made in compliance with Sen Joaquin County Ordinance No.1862 and the rules and regulations bf the San Joaquin Local Health District. Exact Site Address 4150 W. ROCKY POINT COURT. : City/Town TRACY Owner's Name DON COSE & ASSOCIATES Phone 836-0422 Address 19 E. 6th ST. City TRACY Contractor's Name FREITAS ELECTRIC License If 338471 Business Phone 835-2814 Contractor's Address 5362 W. "GD ST. Emergency Phone S/A i Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes X No �. TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ . RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL 'ABANDONMENT ❑ OTHER ❑ PUMP"INSTALLATION 9 PUMP REPAIR REPLACEMENT❑ % I DISTANCE TO NEAREST: Septic Tank 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 ❑ CABLE TOOL Dia. of Well Excavation CX DOMESTIC/PRIVAT,E ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC) ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 0 ❑ CATHODIC PROTdCTION ❑ ROTARY T ('Z. ype of Grout ❑ DISPOSAL �tt OTHER )Other Information G' ❑ GEOPHYSICAL 1 Surface Seal Installed By: PUMP INSTALLATION: Contractor FREITAS ELECTRIC Type.of Pump M H.P. 1A PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: CI State Work Done DESTRUCTION OF WELL: WeII,Dlametsr; Approximate Depth . i De4cribe Material and Procedure I hereby cirtify that_1 have prepared'this application and that the work will be done in accordance with San Joaquin County n 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 Issued, 9 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the.following:"I certify that in the performance of the work forwhich this permit is i'sued, I shall employ persons subject.to,workmari's compensation laws of California." I wit call to Grout Inapejtion prior to grouting And a finalAspection. Signed _ Tile: , • , \ Date: �"�Z�—7� w (Draw Plot Plan pn Reverse Side) F R DEP RTMENT U ONLY PHASE I I 4 Application Ac opted By Date�' Date 4/ 9 Additional Co monis: Phase II Grout Inspection �h��se77�II""I�Final Inspectic, _ Inspection�y Date Inspection By �yrp•.Ioo� Date- 7 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER'$ITE -❑ EACH ❑ January 1 &Received By January 0031 ❑ July 1 8 Received By July 31 REMIT BILLING REMITTANCE $BASE E%PLANATI DATE DATE' REMITTED AMOUNT DUE CHECKED AMOUNT FEE .� LESS - PRORATION PLUS PENALTY OTHER .+ OTHER 9/IBA 7q Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo.2009 STOCKTON,CA 95201