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E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFiCE USE: 1 1601 E. Hazelton Ave. , Stockton., CA 95205 EPermitNo. Iq—6 �Telephone: (209) 466-6781APPLICATION FOR WELL CONSTRUCTIONOR PUMP PERMITsued <br /> (t omp bete , I n Tri pl i tate) <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. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name. Phone &-a2_® <br /> Address I City. L,01-) <br /> Contractor'"s Name .S _ Licensee Phone2o7-- <br /> IS <br /> o7 -IS CERTIFICATE OF WORKIIANS CO"IPENSATION INSURANCE ON FILE WITH -SJLHD? YES 0­ - ` <br /> _ <br /> —TYPE OF WORK Check NEW WELL CI DEEPEN Q RECONDITION [ DESTRUCTION[� <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 -� <br /> PUMP INSTALLATION M PUMP REPAIR( PUMP REPLACEMENT L1 <br /> DISTANCE id� NEAREST. `'" SEPT-P&-TAN_K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALS .1ELD ., _,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 We'sI Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> -7—Geo physical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor, <br /> .; -.. . Type of,;Pump . H.P. <br /> PUMP REPLACEMENT.: _ <br /> ; State=Work.,Do <br /> PUMP R�P <br /> State ,Wo k.Done `- _ <br /> ,. <br /> DESTRUCTION OF WELL: Well Diameter ` �" � i _ Approximate Depth <br /> Describe Materia and Proce ure <br /> I hereby,certify,that, I hav&�,)-ep:ared this application and that the work will be done in accordant <br /> with San-'-J'oaguin ,Caunty-,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 /> I WILL CALL R A GR T PECTION PRIOR TO GROUTING AND A FINA INSPECTION. <br /> SIGNED TITLE: DATE: ,lz_Z9T__-___- <br /> (DRAW PLT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />'APPLICATION ACCEPTED BYZIL, <br /> DATE G V" <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III 'F,INAL INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> EM 14 26 Rev. 9/78 // 1 /9/78' /2M <br />