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h <br /> IR SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � FOR OFFICS • E. Hazelton Ave. , Stockton, CA 95205 Permit No. `� - <br /> Telephone: (209) 466-6781 <br /> SIT <br /> APPLI N FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 2 <br /> - 3 1979, - (Complete In Triplicate) <br /> Application � 0#9#�described. <br /> he San Joaquin Local Health District for a permit to construct <br /> and/or instal, This application is made in compliance with San <br /> Joaquin County Ordinance No'i 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS d CITY/TOWN <br /> Owner' s Name �- Phone <br /> Address, 1 i et r ___ City <br /> Contractor' s Name License# `9 old Phone <br /> IS CERTIFICATE OF WORK!IANI'Si CO ENC TION INSURANCE ON FILE WITH SJLHD? YES k NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ 4 RECONDITION ❑ DESTRUCTIONj3 <br /> WELL'! CHLORINATION'D WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION 1;9 PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> 9 <br /> kA <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE I!!' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �� Cable Tool'-'-- Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I� Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical �� Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor C - ` <br /> Typed of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP I OS'tate .Work Done ;s .1 24tl <br /> DESTRUCTION OF WELL : Wel lli' Diameter A roximate Depth _ <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accorda"nc <br /> with San .Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owne,'r 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 FORA GROUT INS'PE ON P IOR TO GR_ UTING AND A FINAL INSPECTION. <br /> SIGNS I1 LE: DATE: <br /> ( ,�DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APP!ICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS ; <br /> PHASE II GR01�-;1-T;b INSPECTION PHASE III NAL ION <br /> INSPECTION BY ., - DATE— -�r INSPECTION B <br /> ?� <br /> 5 9 2M <br /> 26 Rev. 9/78 �/ <br />