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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -f R-t)VFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,'Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> di <br /> 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 <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 2210 North California ' City/Town Stockton' t <br /> Owner's Name City of Stockton Phone, 944-835 <br /> Address City Hall # tA - City_ Stockton . it. f <br /> Contractor's Name World Enterprises License# 265964, Business Phone 466-0717:. f �l <br /> Contractor's Address P.O. Box- 8598 Stockton 95208 Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD7 Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORI NATIOli WELL ABANDONMENT.® OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR_❑_ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ,f <br /> 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑GEOPHYSICAL Surface Seal Installed By: E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done_ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Couldty <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I,certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which tHis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." j <br /> I willc I for Grout Inspection ' r to grouting and a final inspection. <br /> Signed X Title: Office Manager Date:. 6-11-811. <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By T" DateT'��_� <br /> Additional Comments: <br /> 3 <br /> Phase II Grout lnspection _Pffiase Ili Final!qppection <br /> Inspection By Date Inspection By 1 Date � � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH '❑ January 1 &Received By January 31 ❑ July 1 &Received B,y July 31 <br /> REMIT ` <br /> BILLING REMITTANCE $ <br /> - BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> o <br /> PEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by bale Receipt No. Permit No Issuance Date Mailed Delivered p <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA;95201 J <br />