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SAN JOAQUIN -LOCAL-HEALTH- DISTRICT II <br /> OFFICEFOR <br /> USE.: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. —S? <br />` Telephone: (209) "466--6781 11 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> 44: - <br /> (t omplete In- Tri pI i cate) <br /> +Y 5 <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 mads in compliance°'with °San <br /> Joaquin County.'Ordinance No. 1862 and the Rules and Regulations of- the-San Joaqu�-n Local' Health <br /> District. <br /> EXACT STREET ADDRESS r CITY/TOWN <br /> Owner's Naffie - Phone - - - <br /> Address fter , �'Ci ty <br /> Co.ntractor's Name.. All License#,3,Q PhoneYYZ <br /> IS CERTIFICATE- OF WORKMAN'S COMPtNSATION INSURANCE ON FILE WTTYI SJLHD? YES + 0- <br /> 4 _ <br /> TYPE OF WORK -(Check) : !:NEW WELL DEEPEN 0 RECONDITION C DESTRUCTION ._. <br /> , WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> ' PUMP INSTALLATION 0 PUMP REPAIR d- . PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS SOL/SEEPAGE PIS- OTHER <br /> " PROPERTY LINE - PRIVATE DOMESTIC TELL------- PUBLIC DUMESTxC WELL <br /> ' - INTENDED USE TYPE OF WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool , -Dia, of Well Excavation �1' <br /> rte.: Domestic/private Drilled Dia. 'of Well Casing 41, <br /> I 7Domestic%public: Driven Gauge of Casing !� <br /> -__ Irrigation Gravel Pack Depth of Grout Sea ![ <br /> 4Cathodic Protection Rotary Type of Grout - <br /> Disposal.. Other Other Information <br /> Geophysical N Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P:!i, <br /> PUMP REPLACEMENT:' <br /> State Work Done <br /> PUMP REPAIR: g" (]State Work Done <br /> DESTRUCTION OF WELL "Well Diameter � Approximate Depth_L O-P <br /> Descri bIl <br /> eu teri a an race ure <br /> ;VAa f <br /> I hereby certify 'tha:t I have prepared this application and that the work wilbeidon "r a <br /> e i an <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of_the .San Joaquin Loca <br /> Health District. . Homeowner or licensed agent's signature certifies the following <br /> "I certify tht in the performance of the work for which this permit is issued, `I shal], <br /> not-employ <br /> I' <br /> � p y any- person in such manner as to become subject to Workman's. Compensation <br /> laws of California;' <br /> FI WILL CALL FORaA GROUT INSPECTION PR OR TO GROUTING AND A FINAL INSPECT ON. <br /> SIGNED7 TITLE: DATE: d(4111V` - <br /> D W PLOT L NON REV I 1�. <br /> " OR DEPARTMENT USE ONLY <br /> PHAS E I <br /> APPLICATION ACCEPTED' BY DATE <br /> ADDITIONAL COMMENTS: U 11 <br /> PHASE IIGROUT INSPECTION PHASE JJI4 NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY I�DATE <br /> EH 14 26 Rev. 9 . . -9/78 2M' <br />