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r � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ) /6 s-6 <br /> Telephone: (209) 466-.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued��-�/_ <br /> (Complete In Triplicate) ' <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 /> F Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San .Joaquin Local 'Healt"h <br /> District. <br /> EXACT STREET ADDRESS4CITY/TOWNo <br /> Owner's Name_,C:1 At . �s lel. - - Phone <br /> Address / Ctty.S-L- �Ps-�?Q-L . <br /> Contractor's Name Li cense# Phone �/�' <br /> f "IS CERTIFICATE OF WORKt1AN'S COMPENSATION INSURM14 ON FILE WITH SJLHD? YES No. <br /> TYPE OF WORK (Check) : " NEW WELL 0 DEEPEN RECONDITION DESTRUCTION( <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 ' OTHER{ <br /> PUMP INSTALLATION C7 PUMP REPAIR 0 PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES . PIT PRIVY ---- <br /> SEWAGE DISPOOSA FIELD CESSPOOL/SEEPAGE PIT :� OTHER N <br /> f PROPERTY LI PRIVATE DOMESTIC WELL.?.G1.— PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATION <br /> Industrial Cable Tool _ Dia. of "Well Excavation �Lt4 Domestic/private Drilled Dia. of Well •Casing Domestic/public Driven Gauge of Casing ,rc,42u,d- <br /> =Irrigation Gravel Pack - Depth ;of Grout Seal 1J ,1 --.. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 7Other ' Other ,Information ^ <br /> Geophysical Surface Seal Instd ed by* <br /> f <br /> I PUMP' INSTALLATION: tContractor r <br /> k Type of Pump H.P. - <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: D State 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 accordant <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 CA OR A G UVIN 610N PRIOR TO GROUTING AND A 'FINAL INSPECTION. <br /> SIGNED TITLE: , DATE: ? <br /> DR W PL PLAN' ON REVERS DE <br /> FOR DEPARTMENT UZ ONLY <br /> . PHASE I <br /> ; APPLICATION ACCEPTED 8Y iu DATE 2.. �� ? <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYr ��DATE <br /> EH 14 26 Rev. 9/78 . x 9/78- 2M-_� <br />