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�' } R SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , - Stockton, CA 95205 Permit No. 'el _�M� <br /> ` Telephone: (2O9), 466-6781 <br /> APPLICATION FOR WEJ�L- C S STRUCTION OR PUMP PERMIT Date Issued <br /> This Permit-- Expires i Year From Date Issued 77 <br /> Complete In Triplicate <br /> Application is hereby made toothe San Joaquin Local Health District for a 'permit to construct <br /> and/or install' 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 Saiz Joaquin Local Health <br /> f A--cam .s/S fz 0/=­"'"/'O' � <br /> EXACT STREET ADDRESS -CITY/TOWN <br /> Owner's Name_OEM Phone � � <br /> Address City <br /> Contractor's Name A.IjrAA License Phone <br /> IS CERTIFICATE OF WORKMAN'S CO1MIPENSATIOIN' IINSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLPO DEEPEN O RECONDITION 0 DESTRUCTIONE3 NJ <br /> WELL CHLORINATION p WELL ABANDONMENT p OTHER( <br /> PUMP INSTALLATION C1 PUMP REPAIR.❑ PUMP REPLACEMENT [] O <br /> -- - -' <br /> DISTANCE TO NEAREST: SEPTIC{ TANK, SEWER LINE .PFIT PRIVY --- <br /> SEWAGEjDISPOSAL IEL CESSPOOL/S.EEP�GE PIT - -- OTHER <br /> • PROPERTY LIN V41P RIVATD MESTIC WELLS —* PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTUCTION SPECIFICATIONS <br /> Industrial Ca-bl-e-Tool­. Dia. of Well Excavation ` <br /> Domestic/private Drilled Dia. ofWel I ,Gas ing v. ?I <br /> Domestic/public Driven Gauge of Casing p <br /> Irrigation V Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of`Grout <br /> Disposal Other Othertlnformation <br /> Geophysical _ _ , P:� Surface Seal Installed b : 17,r a <br /> PUMP INSTALLATION: Contractor • � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work .Done <br /> PUMP REPAIR: O 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 t at the'work -will be done in accordance <br /> with San Joaquin County Ordinances , 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 thj.s_per-ma t:i.s. i ss.ued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California." i <br /> I WILL C FORA ROUT I TI RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: , -+ <br /> RAW PLOT L N ON REVS S SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ..I.. - - - - - - - <br /> APPLICATION ACCEPTED BY ' -i <br /> CO�/c� ,. ,. DATE 6 at <br /> ADD'ITIONAL' COMMENTS-. <br /> -- ---- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION 8Y Gam, ' DATE 7,/,,r,/ ? INSPECTION BY _ DAT ' <br /> /ba GiwGt.Pr : -7 � <br />-PW 1 d9A 0__ 1177 : f I�/!47 �'�.. / 'W � 1 1 7AM 9M <br />