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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: e;pd.GG'U CeY�r�ce 1:1IN �•li�y►-' ' zdzZ4 <br /> nsfera e, "TL <br /> e,Suspend b ) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 172_0 C �E,e_,c u/ .q 72,3,x <br /> TER QUALITY *� w, t, p - _ 2s <br /> ApplicationisherebymadetotheSanJoaquinLocalHealth Istrictf rapermittoconstruct �stallthework.hereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and reg lati of the San Joaquin Local Health District. <br /> Exact Site Address south side" Greeley Way west of Fredricksburg Plcity/Town Stockton <br /> Owner's Name City of STockton Phone . #944-8429 <br /> Address - 2500 Navy Drive _ _:: `,:11 vrt_ i . city :-Stockton <br /> Contractor's Name License# .T Business Phone <br /> 1. <br /> Contractor's Address a t' "' �' = Emergency-Phone <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 ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM <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 />} k INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> � <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> r <br /> I�IRRI ION ❑ GRAVEL PACK Depth of Grout Seal - �e <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:' Contractor Delta RlzM <br /> Type of Pump Turbine H.P, 7�) } <br /> PUMP REPLACEMENT: State Work Done re la e colum and re air bowls <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> R 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 County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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." <br /> IUcall �COX <br /> prior to grouting and a final inspection. <br /> s� � <br /> Signed X Title: Jle " A,e, �ly Date: <br /> J. - (Draw Plot Plan on Reverse Sid ) WATER SEWER ERINTEND - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By ho - - - � <br /> Additional Comments: <br /> Phase II Grout Inspection Phasp III Final I pection <br /> Id-- /;7 <br /> Inspection By Date Inspection f7/3�5Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ti <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> Received by Date Receipt No. Permit No. 'I n e ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />