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dSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.75-FA <br /> Telephone:' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued -)-0 78 <br /> This Permit- Expires 1 Year From Date' lssued <br /> Complete. In Triplicate j <br /> Application is hereby made to the San Joaquin Local Health District fora 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 CITY/TOWN --_- <br /> Owner's Name Phone 3 2-1,/d7f4 <br /> Address t Ci ty <br /> I� Contractor's Name Licenseg6�,Q7:N-- Phone , <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOi! INSURANCE ON FILE WITH SJLHD? YES �l0 <br /> TYPE OF WORK (Check) : NEW WELL C DEEPEN 0--- - RECONDITION ❑ DESTRUCTION❑ ��," <br /> �- .. WELL CHLORINATION 1❑ `WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION V2r' PUMP REPAIR❑ PUMP REPLACEMENT LA <br /> DISTANCE TO NEAREST:f SEPT IC::TA€VK SEWER LINESZ?r, PIT PRIVY____ '. <br /> SEWAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER = ` <br /> PROPERTY LINE' -. PRIVATE DOMESTIC' WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE `TYPE OF WELL ! CONSTRUCTION SPECIFICATIONS- <br /> Industrial Cable Tool X` Dia. of Well Exc-'avation <br /> omesti c/private Drill ed,. Dia. of Wel l Ca's i ng ` <br /> `Domes-t4c/pub14c- =Driven Gauge of-Casi g y <br /> Irrigation Gravel Pack Depth of Grout Sea -S--V <br /> Cathodic.. Protection C Rotary Type of Grout <br /> Disposal '- Other Other Information <br /> Geophysical „r�11 Surface Seal Installed by: - _ ) <br /> w - <br /> ^ PUMP INSTALLATION: Contractor e_ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f]State Work Done <br /> PUMP REPAIR: ❑State Work Done y <br /> I DESTRUCTION OF WELL: Well Diameter t Approximate Depth <br /> Describe Material and Procedure i>;�` - <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 Local <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 /> I WILL CALL RR A GROUT INECTION P IOR TO GROUTING A � A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLOT PL N ON REVERSE IDE <br /> FOR DEPARTMENT USE +ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_*" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> FN 1 Q9ti Doti :19-77 <br /> 1/78 2M <br />