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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFI ,E USE: 1601 E. �Hazelton Ave. , Stockton, CA 95205 Permit Na. <br /> ux <br /> Telephone: (209) 466-6781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issue - �2 <br /> i (Complete _In Triplicate) r. <br /> Application is herebymade to the San Joaquin Local Health District fora permit to 'construct ,W <br /> and/or install the work'lherein described. This applicationjis made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local, Health k� , <br /> District. <br /> -EXACT STREET ADDRESS 530 E. Charter Way CITY/TOWN St c <br /> Owner's Name Senior Service Center Phone 465-5634 <br /> Address Same P.O.j[Box 729 XXX _ City Stock <br /> Contractor's NameVetter Plumbing Co. , Inc. Licens0S202228 Phone 463-1705 <br /> IS CERTIFI-CATE_.OF -WORKt1Atl S---COfIP-ENSATIOtd INSUR-AlcICE-.ON.�FI-LE"WITH=SJLHD? YES NO` <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> kLL CHLORINATION ❑ J-WELLsABANDONMENT PD OTHER C3 - <br /> SUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEDER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIAT OTHER. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL_M_ PUBLIC DOMESTIC WELL <br /> E INTENDED USE TYPE OF-WELL-. CONSTRUCTION SPECIFICATIONS . <br /> Industrial ; Cable ToFl ;...Dia..-of Well- Excavation <br /> Domestic/private . �- Deilled . Dia. of Well Casing <br /> Domestic/public Driven' Gauge of Casing <br /> Irrigation Gravel Pack - Depth of Grout Sea <br /> Cathodic Protection Rotary "� Type.,of; Grout <br /> Disposal Other Other-:Information <br /> Geophysical , : � Surface Seal Insta ed b <br /> PUMP !INSTALLATION: Contractor <br /> �7ype of Pump H.P. <br /> PUMP REPLACEMENT:. []Sta a Work Done <br /> PUMP REPAIR-— .0State.,.Work.Done <br /> DESTRUCTION OF WELL:T. Well Diameter � " . . ,.. �� '\.'Approximate Deptkinknown <br /> Describe Material and, Proce ure� cap and seal <br /> I hereby certify that 'Ii have prepared this application and that the work will be done in accordan4 <br /> with San Joaquin Countyi3Ordinances , State Laws , and Rules and Regulations of..-the San•Joaquin Local <br /> Health District. . Home owner or licensed agent' s signature certifies the following: <br /> ' I certify that in the performance of the work for which this permit is issued, -I shall <br /> not employ any persl6n in such manner as to become subject to Workman's Compensation <br /> laws of California.i' �. <br /> IWILL, CALL FOR GROUT.k.-NSPECTION PRIOR TO GROUTING- AND A FINAL INSPECTION. <br /> SIGN D f 31. � ' TITLE: President DATE: 4/23/79 <br /> ° dr <br /> (DRAW PL T- L N ON REVERSE SID£ <br /> �. -FOR DEP RTMENT USE ONLY �. <br /> PHASE I `- <br /> PPPLICA ION ACCEPTED BYi' Z14 DATE S� <br /> ,ADDITIONAL COMMENTS: C, <br /> PHASE II GROUT INSPECTION m PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA O - 1 <br /> EH ' 14 26 Rev. 9/78 M <br />