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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1.601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 <br /> Telephone: - (209) 466-6781 .I <br /> APPLICATION FOR WELL CONSTRUCT QN OR PUMP PERMIT Date Issued `�d ' 7 <br /> (Eomplete 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 <br /> CITY/TOWN <br /> Owner's Name Mr. <br /> r Phone,36 <br /> Address 0ep '7 A1.1. r <br /> city <br /> Contractor's Name3,1 <br /> ; fLicense# �> Phone ?4J'= <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA1ICE ON FILE WITH SJLHD? <br /> TY-PE--OF-WQRK (Chi : ,NEW WELLD DEEPEN 0 RECONDITION -QDEOTHErx <br /> NWELL CHLORINATION 0 WELL ABANDONMENT ' R0 <br /> ,PUMP INSTALLATION <br /> _ Jj3�. PUMP`REPAIR CJ PUMP REPLACEMENT <br /> 'DISTANCE TO NEAREST: SEPTIC TANK%50' SEWER"`'l NES.1rV.-r' T PRIVY �•��' <br /> SEWAGE DISPOSALfFIELD ` A`.`� CESSP OL/SEEPAGE PIT 'a OTHER <br /> PROPERTY LINE -.-,:PRIVATE DOMESTIC WE-LL� PUBLIC D MESTIC WELL <br /> INTENDED USE ,=� <br /> I� TYPE OF WE'LL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cab1e Tool;`` Dia. of .We 1 Excavation �• <br /> t ______Domestic/private5i Drilled Dia. of Well Casin <br /> Dvmestic/publ i c l Driven �� Gauge of Casing g ., -- <br /> I =v Irrigation i� Gravel—Pack" --- -Depth of Gr6Uit. Sea ve. <br /> athodic Protection Rotary Type of Grout "-Cg: - <br /> I T__�___ Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed by: <br />, PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> o r^ A- r,� <br /> PUMP REPLACEMENT: Q State Work Done W <br /> PUMP REPAIR: []State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Proce ure Approximate Depth <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 C L FOR A GROUT INSPECTION PRIOR TO GROUTING AND A'FINAL INSPECTION. 4 �" <br /> SIGNED p PL L TITLE: -- <br /> DATE:��2—� <br /> REVERSEON SIDE <br /> PHA ,a OR DEPAR MENT USE ONLY <br /> APPLICATION ACCEPTED BY { I <br /> ADDITIONAL COMMENTS: DATE y " z 7 <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BPHASE III .FINAL INSPECTION _ <br /> YE DATE y_ ? <br /> INSPECTION BY <br /> EH -14 26 Rev._9/78 1'7n <br /> r <br />