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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P�FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._7q-'6 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WftL `CGNSTRUCTION OR PUMP PERMIT Date Issued l-.-2-5 '2/ <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for alpermit 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. <br /> EXACT STREET ADDRESS / CITY/TOWN <br /> Owner's Name Phone <br /> Address S'Ray„i City <br /> Contractor's Name License�f1ce/ Phone Z-gWX1Q <br /> ,IS CERTIFICATE OF WORKMAN S COMPENSATION INSURACE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DES7RUCTIO 0 <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIREJ PUMP REPLACEMENT [3 kt <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES . , <br /> PIT PRIVY -.— <br /> SEWAGE DISPOS 4 IELD CESSP OL/SEEPAGE PIT OTHER -� <br /> PROPERTY LINk�-�-PRIVATDO ESTIC WELLLO-L-L PUBLIC DOMESTIC WELL ------ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ IndustrialCable Tool Dia. of Well Excavation O <br /> Domestic/private rifled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing ZO <br /> _Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout —. <br /> Disposal Other ti Other Information <br />-_Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump —H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> BUMP REPAIR: QState Work Done <br /> DESTRUCTION OF-WELL: -Well Diameter —Depth---------- <br /> Approximate <br /> Describe Material and Proc 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 performance 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. " <br />.t. WILL CALL FOR A GROUT INSP IO P OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE <br /> PJAWP L ON REVERSE-S(IPE) <br /> PHASE I' - <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE �Z�' 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSHE—MOON PHASE III F 'NAL 1,NSPECTION <br />'NsPECTION BY DATE INSPECTION BY G,/ DATE <br />".H 14 26 Rev. 9/7$ / 03 9/78 2M <br />