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/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 rDate <br /> Issuedrmit No. <br /> s ' <br /> Telephone: (209) 466-6781 :, . , <br /> � <br /> APPLICrI�'ION- FOR WELL CONSTRUCTIQN OR PUMP PERMIT -�- --. <br /> (E,omplete In Triplicate}. 1 <br /> . , <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 wi'th .San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations, of the San Joaquin Local Health <br /> ' ' <br /> District. <br /> 'EXACT STREET ADDRESS ./9 9"76 o CITY/TOWN_ <br />{I ,Owner's Name v r Phone K5 N <br /> 5 <br />` :Address _5 C) <br /> City <br />' Contractor.'s Name ar ,,, License0/ Phone_ <br />� ;'I5 CERTIFICATE .OF WORKMAN'S CO'1PENSATION SURARE ON FILE WITH SJLHD? YES 0 <br /> LY P L OF W0RK_(Check)x: NEW WELLEO DEEPEN 17 RECON�DITIONW { DESTRUCTION[ r <br /> WELL CHLORINATION <br />� - 0 WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION 0 PUMP- .REPAIR-0 PUMP REPLACEMENT � p � <br /> DISTANCE T ` - r <br /> O NEAREST: SEPTIC -TANK-t_6b SEWER LINES --_ -PIT PRIVY <br /> SEWAGE DISH SALIELD�p r CESSP L/SEEP GE PIT OTHERPROPERTY LINEfPRIVATCOMESTIC WELLZ�_ <br /> PUBLIC DOMESTIC WELL --- 'S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool —CRi of Well Excavation r <br /> —X—Domestic/public <br /> Drilled Dia, of Well Casing .. <br /> Domestic/public Driven <br /> Gauge of Casingj <br /> Irrigation _Gravel Pack Depth of Grout Sea <br /> Cathodic Protection ��Rotary Type of Grout a <br /> Disposal Other Other Information <br /> Geophysical - T— Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor ,- <br /> Type of Pump . H. <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP REPAIR. ❑State Work Done, <br /> DESTRUCTION-SOF=WELL: r. -Well° Diameter - -� <br /> Describe Materia an Procedure - - "'App roxi'mateDepth <br /> I hereby certify that I have prepared this application and that the work wi1.l be done in accordance <br /> with San Joaquin County Ordinances, .State Laws, and Rules and - Regulations of` the San Joaquin Local "4 <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 /> rf PRIOR TO GROUTING AND A'FINAL INSPECTION. <br /> I WILL CAL FORA RQ T I i. <br /> SIGNED � <br /> TITLE: DATE: S <br />- L ON REVERSE IDE z <br />'HASE I OR DEP R MENT USE NLY <br />'PPC LICATION ACCEPTED BY S i <br /> 1DDITIONAL COMMENTS: DATE 3`� <br /> PHASE IIGROUT INSPECTION <br /> NSPECTION BYPHASE III INAL NSPECTION <br /> _ DATE INSPECTION BY .DATE <br /> H 14 26 Rev. 9/78 /64' � P- -.�' �� �, ,*7� , nil, ' <br />