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SAN JOAQUIN LOCAL HEALTH; DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No? . <br /> Telephone:. , (209) 466•-6781 <br /> 1` APPLICATION FOR WELL tCON�ST-RUCTION OR PUMP PERMIT Date Issued G _t <br /> (complete In" Tripl i'cate) <br /> Application is 'hereby made to the San Joaquin Local Health District for a permitto construct <br /> and/or install the work herein described. . This application is made in compliance- with San <br /> Joaquin County Ordinance Nd. 1862. and the Rules and' Reg' u'laL. 'o of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDR SS �� CI1'YJTOWW/ <br /> s <br /> Owner's Name � � (!__7z Phone .-4?-/' a <br /> Address City <br /> Contractor's Name � ' l-�d� License#, �3�Phone <br /> r <br /> IS CERTIFICATE OF WORK"IAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES � 0' <br /> TYPE OF WORK (Check) : NEW .WELLt' DEEPEN ❑ RECONDITION DESTRUCTION❑ .4 p� <br /> WELLi CHLORINATION p 'WELL ABANDONMENT❑ OTHER Q <br /> PUMP INSTALLATION ;4 PUMP REPAIR❑- • PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- PIT PRIVY -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPPZE PIT .. OTHER - <br /> PROPERTY LINE - PRIVATE DOMESTIC WEI_L� PUBLIC DURESTIC WELL <br /> INTENDED USE.3 F TYPE OF .WELL_ -- CONSTRUCTION SPECKICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �.' <br /> -Domes ti c/private Dri 11 ed Dia. of Wel l -Ca-s i"ng- <br /> - Domestic/public Driven Gauge of Casing ' - , , I <br /> Irrigation Gravel -Pack. Depth of; Grout Sea <br /> Cathodic Protection L/kotary Type-'of Grout <br /> i Disposal Other Other Information <br /> I Geophysicali Surface Seal 'Insta Gd, <br /> PUMP INSTALLATION: Contractor <br /> Type' of Pump _ :- . <br /> ' PUMP REPLACEMENT: F � <br /> estate Work Done <br /> PUMP REPAIR: . ` ❑State Work Done <br /> i DESTRUCTION OF WELL: Well-Diameter Approximate Depth <br /> Describe. Materia and Procedure <br /> e � <br /> i I hereby" certify that I have prepared this application and that the work will be done in 'accordar <br /> with San Joaquin County Ordinances;, State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Hearth 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 /> Knot em to an <br /> p y ' y person in such manner as to become subject to Workman's Compensation �- <br /> Taws of C.a 'fornia <br /> I WILL C GROU i SPECTION PRIOR TO GROUTINGLANU FINAL INSPECTION, <br /> SIGNED v -g TITLE: DATE: 4� 2 �7 <br /> -" <br /> (DRAW PLT PLAN. ON REVERSE SIDE <br /> - FOR DEPARTMENT USE ONLY <br /> PHASE -I .-- -- <br /> APPLICATION ACCEPTED BY VA� r.w DATE &t;L-19 _ <br /> ADDITIONAL COMMENTS: <br /> P ASE I GROUT INSPECTION PHASE III INAL INSPECTION <br /> BY Q DATE -k3-19 - <br /> INSPECTION BY DATE �R <br /> EH 14 26 Rev. /78 ' _ .: 9J7$ 32M <br />