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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton, Ave. ; Stockton, CA 95205 Permit No. ��' '6 <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued &/,C3-7f <br /> This Permit Expires, 1 Year From Date Issued <br /> 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. <br /> EXACT STREET ADDRESS <br /> --- a 7 _ ,---- 6&2, - CITY/TOWN <br /> Owner's Name \ Phone_3 6g--(,.Z4 !X <br /> Address �- �. City <br /> Contractor' s Name ;# p Lilcense Phone <br /> IS CERTIFICATE OF WORKMAN'S COFIPENSATION' INSURANCE ON FILE WITS[ SJLHD? YESN0 } <br /> TYPE- OF WORK (Check) : NEW'WELLz'C DEEPEN ❑ .RECONDITION Q DESTRUCTION( <br /> WELL CHLORINATION ❑ ' WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION 01, -PUMP REPAIR p PUMP REPLACEMENT j' <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � t <br /> PROPERTY LINE -. "PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> I'NTENDED`USEPE 0 WELL CONSTRl1CTI0N"S'PECIFICATIONS 7 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gaugeof Casing <br /> Irrigation Gravel Pack Depthiof Grout Sea; i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other: Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump l H.P. <br /> PUMP REPLACEMENT: aState Work Done ,u,Q.Q � :— <br /> PUMP REPAIR: <br /> ❑State Work Done ' � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t t <br /> f <br /> I hereby certify that I have prepared this application and `that the work will be done in accordancE <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Locals <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 peemit, is issued, I shall l <br /> not employ any person in such manner as to become subject to Workman 's Compensation ? <br /> laws of California. " <br /> I WILL CALL FOR A GROUT 1,NSPECTIOX PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:(— <br /> W PLOT PL N ON REVERSE ' DE <br /> FOR DEPARTMENT USE ONLY a <br /> PHASE I <br /> APPLICATION ACCEPTED BY ! DATE r' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Fla. 1 d9F.• De kp ' '1 7_77`" rt /7S2 7M <br />