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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 96205 Permit Na. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FORWELLCONSTRUCTION OR PUMP PERMIT Date Issued.- _7 <br /> (,Complete In Triplicate) <br /> Application is hereby made to the 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 San Joaquin Local Health <br /> District. Lo/ �L(* R-a bf rr 7)q /sc xEP. e /c, <br /> EXACT STREET ADD ESS r *1!5' CITY/TOWNl`� <br /> Owner's Name - Phone___VA y.., '7e,1�3 � <br /> Address '' City__ C/ j'71'ers <br /> Contractor's Name rW Licensee Phone_ ( 3 <br /> -4.IS CERTIFICATE Of WORKMAN'S COMPENSATION INSURANCE/ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN p RECONDITION M DESTRUCTION C °^ <br /> WELL CHLORINATION D WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION Q.- PUMP REPAIR C7 PUMP REPLACEMENT [� � <br /> 6� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES rO' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Ali CESSPOOL/SEEPAGE PIT OTHER <br /> � <br /> f PROPERTY LINEJ;4PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEL <br /> INTENDED USE TYPE OF.WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout SealCathodic Protection Rotary Type of Grout <br /> Disposal - Other Other Information <br /> Geophysical Surface Seal Insta ed b <br /> PUMP INSTALLATION: ContractorG ! <br /> Type of Pump ,Q3 H.P. -- ` <br /> PUMP REPLACEMENT: <br /> []State Work Done .- <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> I hereby certify that I have prepared this' application and that 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 pgrformance of the work for which this permit is issued, I shall <br /> not,employ any person in such manner as to become. subject to Workman's Compensation <br /> laws of California." JIN <br /> I WILL CALL FOR R GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - ,.. <br /> TITLE: DATE: "3/&Z2 <br /> DR PL T PL N ON REVERSE SIDE <br /> PHASE i R DEP TMENT USE ONLY <br /> APP LICATION ACCEPTED <br /> ADDITIONAL COMMENTS: DATE 3112 1-72 <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br />=H 14 26 Rev. 9/78 DATE Z.-15-19 <br /> 9/78 2M <br />