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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, CA 95205 Permit No. 77- /-/q7 <br /> , <br /> Telephone: (2.09) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue&5-7 „ <br /> (tomplete .ln Triplicate) :> - <br /> 'iApplication is hereby made to the San Joaquin Local Health District- for a permit to construct <br /> ,and/ar ? the work herein described. This application is .made in compliance with San <br /> nstal.7 <br /> iJoaq`uirr Cou.nty Ordinance ctNo. 1862 and the Rules and Regulations of the San Joaquin: Local Health <br /> `fstr' , <br /> AEXACT, STREET ;ADDRESS" ho CITY/TOWN ���`"'�',✓ ' <br /> :Owner's Name <br /> �- Phone 9S/—sy. 1o�.l <br /> ,'Address y YS FSP # <br /> City -C�6 y°f�.✓ <br /> `Contractor's fame ['ak` License# Phone 7 gy- y? y <br /> 'IS. CERTIFICATE>OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES O x� <br /> <TYPE' OF, WORK.,-(Check,) ' :NEW-WELL W DEEPEN ❑ RECONDITION ❑ DESTRUCTION[� <br /> WEI-L�CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 <br /> Y PUMP INSTALLATION [ PUMP REPAIRC3-- - PUMP REPLACEMENT Q_ <br /> ..DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES PIT PRIVY <br /> SEWAGE DISP SEAL—FIELD - CESSP OL/SEEPAGE PIT OTHER Q� <br /> PROPERTY LINE - PRIVATE DORIESTIC WELL ��-�� PUBLIC DOMESTICEi�'LE_ �e <br /> INTENDED USE TYPE OF-WELL.- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool [Ha-. . of Well Excavation <br /> --_I,-'Domestic%pri:vate Drilled Dia. of,Well Casingy ,�;v. <br /> Domestic.%public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of GroudSeal <br /> ya <br /> Cathodic Protection Rotary Type of Grout C <br /> Disposal "y , Other Other Information ._ <br /> Geophysical - Surface Seal Installed b ,. C <br /> PUMP INSTAL-LATION :Contractor D 6, <br /> Type of Pump 3/ <br /> H.P. <br /> PUMP. REPLAGEMENT_: ❑State Work Done 4 <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter__ � Approximate Depth <br /> Describe Material anU Frocedure <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... p.ermit-. is-• issued, I shall 1 <br /> not employ .an_person=.in- such-manner 'asi.to-become subject .to,Wor•kman's Compensation <br /> laws. of Cal_i-fornJa.�" - 1 <br /> I- WILLLEORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: _ <br /> D L T PcmwON REVERSE SIDE <br /> R <br /> PHASE I DEPARTMENT USE ONLY <br /> - <br />'APPLICATIONyACCEPTED BYY DATE �T <br />'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II-I FINAL INSPECTION <br /> INSPECTION 8Y DATE � INSPECTION BY <br /> �_ DATE ,EH 74 26 Rev. 9/78 9/78 2M,-- , <br />