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, <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> F.FICE USE: l/ 1601 E. Hazelton Ave. , Stockton, CA 195205 Permit No. , <br /> Telephone: (209) 466-6781 { ! Date Issued 9a/-78- <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT = <br /> This Permit Expires I Year From Date Issued „ <br /> Complete In Triplicate / <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 /> oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS G L- CITY/TOWN �G .►�� <br /> Owner's Name g v L 4 Phone <br /> Address s. c,L City <br /> Contractor' s Name. , S , License#,::,27190/d_ Phone 89. <br /> 7S CFRTIFICATE OF WORKMAN'S C041PENSATIO"1 INSURA1110E ON FILE WITH SJLHD? YES 'l0 <br /> YPE OF WORK` (Che.cic) : NEW �WELLCj DEEPEN ❑' - 'RECONDITION ❑ " bESTRUCTION12 - -WELL, CHLORINATION 0 WELL ABANDONMENT 0 OTHER 5d � �_ A/ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT C] !� ✓ � <br /> DISTANCE TO NEAREST:- SEPTIC TANK SEWER LINES_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Cr <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> C INTENDED USE TYPE OF WELL ~ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool - Dia. of Well Excavation <br /> t Domestic/private Drilled Dia, of Well Casing <br /> p 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 'r. ge'l SA .✓ <br /> _ Type of Pump H.P. y <br /> PUMP REPLACEMENT: - CIState WorkDone <br /> PUMP REPAIR: _❑State Work Done <br /> DESTRUCTION 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 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 FOR 44ROUT INSPECT ON ZIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAR ON REVERSE SIDE <br /> R.DEPART ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. - :,• DATE �/Z77,P <br /> t ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE IIIFINAL INSPECTION <br /> INSPECTION BY DATE }• `.' '' `` - !t INSPECTION BY DATE <br /> '7'1 <br /> �' + 1 /78c'i <br />