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�'+ �G SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r�QR OF CE USE: 6 1 . , alton Ave. , Stockton, CA 95205 Permit No. 7 12_-Fl, <br /> _ <br /> e hone: (209) 466-6781 <br /> APPLICATION F JELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> .�u 31979 <br /> (Complete, In Triplicate) <br /> 3AB!�erein <br /> Application is hereb �'Joaquin Local Health District for a permit to construct <br /> and/or install the woribed. 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. _ <br /> EXACT STREET ADDRESS 3 -� h CITY/TOWN <br /> Owner's Name w Phone <br /> Address e ?! <br /> ' city__ ' ..- <br /> 'Contractor' s Name Li cen e# Z '' Phone��t L 'Y•- 6 -- <br /> TS CERTIFICATE CF WORK!iAN'S Com ,JS TI01111 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER ❑ - V <br /> } PUMP INSTALLATION ❑ PUMP REPAIR® PUMP 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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool :Dia. of Well Excavation <br /> �c Domestic/private Drilled 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 Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> ..PUMP REPAIR: State Work Done <br /> DESTRUCT-TON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> -with San Joaquin County prdinances , 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 is- issued, I shall <br /> certify that in the performance of the work for which this permit� <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California . " <br />_. � WILL CALL FOR A GROUT INSPECT ON R O GROUTING AND A FINAL INSPECTION. <br /> SIGNS ` " TLE: DATE: <br /> 1 4e DRAW PL PL ON REVERSE SIDE <br /> FOR DEPARTMENT U E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �� �� <br /> i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY�xe, -_ DATE// 7F <br /> f 5279 2M <br />