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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. ,° S"tockton, CA 95205 Permit No.2y- 6,119 <br /> Telephone: (.209.) 466-6781 <br /> APPLICATION FOR WELL-¢CONSTRUCTION OR PUMP PERMIT ' Date Issued,/,�._/J-78" <br /> This Permit Ex ires 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 /> 4oanuin County Ordinance No. 1862 .and the Rules and Regulations of the San Joaquin Local .Health <br /> Distr?ct. <br /> EXACT STREET ADDRESSj' S o' �,(sf R A. TTY/TOWN <br /> v.v <br /> Owner's Name0. Phone_ ` <br /> Ad d re s s � - `�- . ,... C i t �' •_ �-��____._ <br /> hl"cv <br /> Contractor' s Name' <br /> w u u License# Phone 3 <br /> IS CERTIFICATE OF 1C -nN FILE-WIT-H- SJtHD?' ' YES' _ -NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION p fi WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK_&,W('SEWER LINES PIT PRIVY o <br /> SEWA <br /> GE_ DI.SPOSAL FIELD CESSP00 /SEEPAGE_PIT OTHER <br /> r PROPERTY LINE PRIVATE DOMESTIC WELL - PUBLIC .DOMESTIC WELL In <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation al <br /> Domestic/private Drilled Dia. of Well Casing � <br />—Domestic/public Driven - Gauge of Casing <br /> L�— Irrigation, Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout a,r <br /> Disposal Other Other Information <br /> Geophysical �. Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor , 'V <br /> Type of PumpH, . <br /> PUMP REPLACEMENT: '] State Work Done - <br /> PUMP REPAIR: <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an �°Proce ure t <br /> I hereby certify that I have prepared this application andthat 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 ce - <br /> rtifies the following: <br /> I certify that in the performance of the� work for which thi.S permit is issued, I shall <br /> "I <br /> not employ o <br /> p y an y person in such manner as ,to became subject to Workman's Compensation <br /> laws of California. " - — -�-�-- <br /> I WILL CALL FOR A GRO T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE.10 Aa:i Of DATE: <br /> (DRAW PLOT-PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE /-2 <br /> IDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIL FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION ` ` DATE1,;,2�Z- Z� -- <br />:H 1426 Rev. 12-77—... <br />