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cessed When Submitted Properly ompieieof?:�F125 Applications Will Be Pro APPLICATIQ le� FOR OFFICE USE: -t (For Non-Transferable, Revocab s dab1g`� PUMP&WELL ENVIRONMENTAL HEAL WATER QUALITY (COMPLETE IN TRIPLICATE) � j�v herein described.This applicatioh is i Application is hereby made tothe San Joaquin Local Health District fora perrnitto construct an �!n�e San a i Loa It District. k made in compliance with S1 Joa uirrfyinty rd's nee No. 21and the rules and regula City/Town Exact Site Addre I �� Phone i T� Owner's Name I City Address �' I11 License# Buri s Ph v Contractor's Name Emergency Phone 1� Contractor's AddressNo ! Is Certificate of Workman's Compensation EnatLinsurance on File With SJ13 DEEPEN 0 RLHCONDITION❑ DESTRUCTION[] OF WORK (CHECK): ❑ WELL El OTHER 13PUMP INSTALLATION 13PUMP REPAIR - i WELL CHLORINATION , REPLACEMENT❑ Sewer Lines _ Pit Privy DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other Sewage Disposal Field Public Domestic Well Property Line l Private Domestic Well 3 INTENDED USE TYPE OF WELL 11 CABLE TOOL Dia. of Well Excavation ❑ INDUSTRIAL Dia. of Well Casing ❑ DOMESTIC/PRIVATE 11DRII LED ; ❑ DRIVEN Gauge of Casing f 11 DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal ❑ IRRIGATION ❑ ROTARY Type of Grout •- ❑ CATHODIC PROTECTION ❑ OTHER Other Information ❑ DISPOSAL Surface Seal Installed By: ❑ GEOPHYSICAL PUMP INSTALLATION: Contractor H.P. Type of Pump 10 State Work Done PUMP REPLACEMENT: ❑ j PUMP REPAIR: tate Work Done Approximate Depth DESTRUCTION OF WELL: ! Well Diameter Describe Material and Procedure p I 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 Distnc . Horne owner or licensed agent's signatunce of the work for which this permit re certifies the following:"I certify that in the performa is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 1 -contracting signature certitles the following:"I certify that in the p Contractor's hiring or sub erformance of the work for which this p d, l o e joy persons subject to workman's compensation laws of California." Iw Grou In pe an prior t grouting and a final inspe -on. Dale: ) Titl Signed 'I I {Draw Plot Plan on Reverse Side) 3" I OR PARTM NT USE ONLY PHASE I Date Application Accepted By Additional Comments: ' se 111 Fina Inspection Phase 11Grout Inspection Date CCJJ Inspection By Date Inspection By— r• pER UNIT [3 PEA SITE REMIT EACH ❑ January i;a Received 6 anuary 31 © July 1 E Received By July 31 Fee Is Due: 11 ANNUALLY ❑ I BILLING REMITTANCE AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED I AMOUNT FEE 3 LESS PRORATION F f PLUS 1 PENALTY OTHER OTHER r I. qIf 7`1 - Permit No. Ij issuance Date Mailed Delivered - Received by Date Receipt No: CA 95201 1601 E.HAZELTON AVE,,P.O.aoa 2009 STOCKTON, w APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES :�