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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - V fFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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-ander-he RuT n "latians of the San Joaquin Local Health <br /> District. ` IG i <br /> EXACT STREET ADDRESS 1z <br /> �rr cart ,/ 4,7- CITY/TOWNP` �-��`J� , <br /> Owner's Name - <br /> IM4Phone <br /> Address 5__. O's ar 2. A v' <br /> City_ <br /> Contractor's Name /eco, —+ <br /> icense# ; 7� Phone 4 6 <br /> IS CERTI FI,CATE -OF WORKMAN'S COP"PENSATIO'J INSURA*ICE ON FILE WITH-SJLHD? A <br /> YES A— <br /> No <br /> TYPE OF; WORKry-(Check--): NEW WELL U DEEPEN❑ RECONDITION 0 DESTRUCTION[� <br /> .,a <br /> WELL CHLORINATION Q WELL ABANDONMENT o OTHER 0 <br /> PUMP`INSTALLATION C PUMP REPAIR D-, PUMP REPLACEMENT 0 OQ ' <br /> DISTANCE TO NEAREST: SEPTIC <br /> TANK SEWER �iNES ` PIT PRIVY �3 <br /> E DISP SO AL fIELp/goC SSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/-0 RIV Tib E DOMESTIC WELL PUBLIC DOMESTIC WELL— <br /> INTENDED USE TYPE OF WELL.-- -,, <br /> .IndustrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of WeT Excavation <br /> Domestic/private Drilled ` Dia, of Well Casin <br /> Domestic/public Driven g <br /> Di <br /> _Irrigation Gauge of Casing <br /> __ Gravel Pack Depth- of Grout Sea <br /> _L _Cathodic Protection Rotary . ' Type, of Grout <br /> isposal Other Other Information . <br /> .� GeaphysicaT A Surface SeaFInsta ed • <br /> PUMA INSTALLATION: Contractor e1111V'C!!�'/l U ` <br /> ' Type of Pump , �f �- <br /> pUMP REPLACEMENT: ❑State Work Done <br /> PUMA REPAIR: Q State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter _ �{ <br /> Describe Materia an race ure -_. Approximate Depth i <br /> I herebycertify that' l have prepared this application and that the work will be dono'in acco'r <br /> dance <br /> with San .Joaquin County Ordinances , State Laws , and Rules and Regulations of the San-JoaquinLocal � <br /> Health Di'st'rict. 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 />[ WILL GALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND INAL 'INSPECTION. <br /> i.IGNED f) 7 <br /> TITLE: '� DATE: T <br /> D W PL T L N ON REVE SE SIDE <br />'RASE I FO DEP RTME USE ONLY , <br />[PPLICATION ACCEPTED BYtDATE <br /> ADDITIONAL -COMMENTS: DATE .. i <br /> PHASE II GROUT INSPECTION <br /> NSPECT16N BY DATE PHASE III INAL INSPECTION ' <br /> H <br /> 74 26 Rev. 9/78 INSPECTION BY DATE <br />