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SAN JOAQUIN LOCAL HEALTH DISTKICI <br /> FogFFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton, CA 95205 Permit No. y�- <br /> Telephone':' (209) 466=6781 gate Issued <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT <br /> This Permit Ex ires ..1 Year From Date Issued, < Y: <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health �District 'forcnmPliancetwith nSanuct ; <br /> and/or-'install the work herein described This application is made P <br /> ,!oaquin County Ordinance No. 1862 and the Rules and-Regulations of the San Joaquin Local Health <br /> Cistrict'. <br /> EXACT <br /> ' STREET ADDRESS �p CITY/TOWN <br /> Phone (� <br /> Owner's Name <br /> City <br /> Address <br /> License# ti1yL1_ Phone �q <br /> Contractor' s Name <br /> SSC-LR 'T' �TCA7E�•Of-IdOE'1CtrAt� S C01f'EPISA Y01 INSURA' 10E Of1aF'It"E'1^1'I'T 1"SDLHD. YES 1 <br /> 41 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION Q D><STRI CT'ION'❑ "i <br /> WELL CHLORINATION C3 WELL <br /> 0 PUMP REPAIRND <br /> aNT MP REPLAOTHERCE ENT 0 <br /> PUMP IN <br /> r. <br /> If DISTANCE TO NEAREST: SEPTIC TANK,(D'- SEWER LINES ;- "PIT--PRIVY- � - G- <br /> S;EWAGE DISPOSAL MELD CESSPOOL/SEEPAGE PIT OTHER . <br /> SEWAGE <br /> Y LINE9LO RIVATE DOMESTIC: WELL _ _ PUBL. C DOMESTIC WELLPROP �c <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF 'WELL i <br /> Industrial -Cable Tool Dia:-- W <br /> 1Excavati ani .t, <br /> Domestic/private Dr�11ed Dia. of Well Casing_ . — <br /> Domestic/public Driven Gauge of Casing ,` <br /> Gravel Pack Depth of Grout Sea <br /> Irrigation � ' <br /> Cathodic Protection Rotary. Type of Grout " �, <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal''`Instal<led b <br /> PUMP INSTALLATION: Contractor -�- <br /> ` Type of Pump ; H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP' REPAIR: OState Work�Oone- <br /> DE-STRUCT-1-a 9F-WELL: Well-Diameter-... i <br /> - —=-- Approximate <br /> ;Describe Materia ' and Procedure <br /> �I/. 1 <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 Loca- <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 01 <br /> laws of California." <br /> " I WILL CA FOR A GROUT INSPECTION PRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> SIGNED <br /> Y ,� .TITLE- DATE: <br /> 2Ld2-i-- <br /> DR W P T PL N ON REVE SE SIDE <br /> FOR D PARTMENT SE ONLY _ <br /> PHASE I DATE 1 � <br /> �---,-�---- ..- <br /> APPLICATION ACCEPTED BY - "� <br /> ADDITIONAL COMMENTS: Pr ASE III INAL NSPECTION -. <br /> PHASE II G INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �`"� 1/78 2M <br />