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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F5� FF CE USE: - 1601 f `Hazelton- Ave. , Stockton, ,CA .. 95205- . = Permit No. - ,5 <br /> Telephone (299) .466-67$1 <br /> "' Date Issued <br /> APPLICATION FOR' WELL CONSTRUCTION OR PUMP PERMIT <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 f7 7 S P 'p CITY/TOWN d� <br /> Owner's Name i L. Phone, -3 6 2=2L <br /> Address F-fo City W/ <br /> Contractor's Name /VfLicense# G Phone <br /> F IS�.CERTIFI-CATE�OFwWORKIIAC4'-S-COMPENSATION'INSURAt•I 'ON'FILE WITH SJL Hfl? YES _._. 0 <br /> L TYPE- OF'"VJORKC (Check)ANEW WELLiE� DEEPEN El RECONDITION C] DESTRUCTIONd <br /> e WELL-CHLORINATION Q WELL ABANDONMENT 0 OTHER( <br /> PUMP INSTALLATION Q PUMP .REPAIR L—l .. PIMP REPLACEMENT E:1 J <br /> ; DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES ° PIT PRIVY;, � � <br /> SEWAGE DISPO�AL�FIfLDf CESSP OL/SEEPAGE PIT, OTHER <br /> PROPERTY LINW6 PRIVA�ESTIC WELL PUBLIC DOMESTIC —WE-[L-- <br /> INTENDED <br /> EAL INTENDED USE ' TYPEOF WELL: y CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool t --Di-a:—of- We I I Excavation /,4,11 <br /> ti_ _, Domestic/pr.ivate Drilled Dia. of Well Casing <br /> Qomestic/public Driven Gauge of Casing s , Q_. <br /> Irrigation Gravel Pack ' � Depth of Grout Seal ' - - ---` <br /> F- _ Cathodic Protection Rotary ', Type of; Grout r o Me E2, <br /> '---^ Disposal Other . � : _ Other 4hformat on <br /> _w_�eophysica� , ' Surface Seal Installed b <br /> PUMP INSTALLATION: `',) Contractor -, <br /> Type- of Pump H.P. <br /> :LUMP REPLACEMENT: []State Work Done <br /> iPUMP REPAIR: QState Work Done1e - <br /> [DESTRUCTION OF WELL: Well Diameter'; ` ' '" ~Approkimate Depth <br /> Describe Ma'te'rlal and Procedure <br /> CI 'hereby certify that I have prepared this. applicati,on and that the work will be done in accordance <br /> with San Joaquin County Ordinances; State Laws, and ,.R'u3-es and Regulations of the San Joaquin Local <br /> Health e 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 /> k laws of California. " <br /> I WILL CALL FOR A GROUT -I.NSPECTION,,PR-IOR. TO,GROUT-I.NG--AND A-FfiNAL-INSPECTION". <br /> SIGNED 2; <br /> 5 TITLE- DATE: <br /> WN PL <br /> REVERSE SIDE) <br /> WASE I R DEPARTMENT USE ONLY <br /> ;APPLICATION ACCEPTED BYJ DATE : 1.2 F '7 9 <br /> %DDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> XPECTION BY DATE -- ' INSPEC1iION BY DATE 7 -je1 <br /> '.H 14 26 Rev. 9/7$ .� ` 9/78 2M <br />