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SAN JOAQUIN .LOCAL HEALTh! DISTRICT <br /> F�UFFICE USE.: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone': (209) '466-6781 <br /> APPLICATION FOR WELL CONST RUCTION. OR PUMP PERMIT Date issued �/y-7 <br /> This Permit Expires 1 Year From Date Issue Lf <br /> Complete• In Triplicate Iq 2/s <br /> f Application is hereby made to the San Joaquin Local Health District for a permit t& construct <br /> and/or .ins.tall the work herein described. This application is made in compliance with San : <br /> Joaquin County ,Ordinance No. 1862 and the Rules and .Regulations .of. the San Joaquin Local Health <br /> District. I �� �- �� y�i� /5��1� <br /> EXACT STREET ADDRESS wo e CITY/TOWN <br /> Owner's Name t; Phone -,5—PO —a 7Z <br /> AddressES ��• v r> l City <br /> Contractor's Name Al -s License# 5 Phone _5_ l -7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATi0t1 INSURANCE ON FILE WITH SJLHD?^ YES X NO <br /> TYPE OF WORK(Check) - ,N W''WEL Q a DEEPEN 0 RECONDITION [:] DESTRUCTION[ <br /> 'WELL'-CHLORINATION D WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION JZ PUMP REPAIR❑ PUMP REPLACEMENT Q \ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .54- P__- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 0TH R NO <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE .TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private DH11 ed Dia. of Well Casing` <br /> Domestic/public Driven Gauge of Casing. <br /> Irrigation Gravel Pack Depth of -Grout'Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal Other Other- Infarmation <br /> Geophysical Surface`'-Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -u,r-6�`;�,� -- --..._ H.P. 342 <br /> PUMP, REPLACEMENT: F]State Work Done ' <br />!-.:.PUMP. REPAIR: _ _ 4 QState_.Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' Approxii�te�Depth <br /> Describe Materia an Procedure Z' <br /> I hereby cer.ti fy °that I ha--v_e,prepared {this _application and that the work will be idone in accordance) <br /> with San Joa uin County Ordinances „Sta et laws; and Rules—and Reguµlatians of the San Joaquin Local <br /> q <br /> Health District. Home owner oral"icensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall i <br /> not employ any person in'llsuch manner as to become subject to Workman 's Compensation ' <br /> laws of California. " . . <br /> I WILL CALL FOR A GROUTA NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t TITLE: DATE: 3f7t <br /> f <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ,FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . 4+„ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III JINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> SEH 1426 Rav 19-77 �? <br /> y f-�dn n w. <br />