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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton , CA 95205 Permit No. <br /> Telephone":'° =(_209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued r <br /> k- (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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. A FS_.3 Al. C/r e,a�z :t,o,.W <br /> EXACT STREET ADDRESS G4/0.�. . I CITY/TOWN F` - 1_<4-&z-1 <br /> Owner' s Name Phone f-- � <br /> Address <br /> f <br /> Contractor' s Name ,!/, �. License#,�1S e Phone {`� -417.4 <br /> IS 'CE1RTIF'ICATE OF W0_RK11AN'S CO";PE^aSATIO'N Ii1SURANCE ON FILE WITH SJLHD? YES <br /> r TYPE OF WORK (Check) : NEW WELLING DEEPEN C] RECONDITION ❑ DESTRUCTION n <br /> �,WELL`rC'HLORINAT'ION 0 -WELL -ABANDONMENT ❑— "OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: ,SEPTIC TANKS SEWER LINES JS-°_IPIT PRIVY-6_ <br /> _SEWAGE':DISPOSAL FIELD_L4 4 -- CESSPOOL/SEEPAGE PIT ; - - OTHER- - <br /> r ' PROPERTY LINE10PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL - <br /> E 4 INTENDED USE TYPE OF WELL `- CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable To Dia. of Well, Excavation— <br /> Domestic/private X Drilled Dia. of W011Casing °e <br /> --Domestic/public Driven Gauge of_Casi-ng`.` , ,0 /?,Vc <br /> Irrigation _Gravel Pack . _ -Depth of Grout Seal ; <br /> Cathodic Protection V Rota-ry - Type of Grout <br /> Disposal r i < '� : Other `JOther Informati on �. <br /> Geophysical ` f Surface Seal Instal ed b f� « : <br /> " PUMP JNSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: $f F-J S.'ta.te-_Work_D.on.e...__ <br /> r -PUMP •REPAIR: 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 accorda <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> certify that in the performance of the work for which this permit is issued, I shalll <br /> 0 not employ any person in such manner as to become subject to Workman' s Compensation <br /> r' laws of California . " <br /> 'I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: ,5! '`a <br /> DRAW-700T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENX USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ; <br /> r ADDITIONAL COMMENTS : <br /> PHASE I I- GRO!'T=:INSPECT 0 --- -^ - -� PHASE.1I Ir FINAL_INSPECTI.ON_ .. <br /> I'E!l 14 26 Rev. 9/78N�'PECTION BY —DATE � -° "��— -INSPECTION`'BY ' �` '' - -DATE 1� <br /> 5/79 J 2F <br />