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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fL_OF'N*CE USE: 1.601 E. Hazelton Ave. , .Stockton, CA 95205 Perm t No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Date Issued ,;2 <br /> (fomplete , 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 /> Di stri ct... <br /> EXACT STREET ADDRESSCITY/TOWNS --- <br /> Owner's Name o Phone y • �'L`L� <br /> Address -, - c . fo, Jz� n City <br /> Contractors Name . t, Li cense#/,?J,;k4:.Vhone g7 q6_1 3 V `7 <br /> IS CERTIFICATE -OF WORKMAN'S COiiPENSATION INSURANCE ON FILE WITH-SJLHD? YES ' 0- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION CJ <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER( <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK11pq SEWER LINES ) S' 6 PIT PRIVY 4_ � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY' LINE - PRIVATE DUMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF -WELL.- CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cabl_e.-Tool-- �--_Di-a. of- Wel-1--Excavation 1 112— . <br /> ,Domestic/private �-�. Drilled Dia. of Well Casing <br /> Domesti c/publ i c Driven Gauge of Casing /0 _ <br /> f —Irrigatfon � Gravel Pack Depth: of Grout Sea t'—z� ` <br /> _ Cathodic Prote,cton,., _�Rotary-, Type of Grout <br /> Disposal ,F Other^ Other Information `=} <br /> �r Geophysical � t Surface Seal Installed by: <br /> PUMP -I LL ;:1C_on'tractor �F3 . ' <br /> r PUMP REPLACEMENT: ]State Work -Donee ' <br /> Y <br /> PUMP-REPAIR: ❑State Work Done <br /> F , <br /> DESTRUCTION OF WELL:' Well Diameter _ _..Approximate Depth <br /> - Describe Materia "an Procedure <br /> k1 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 /> f not employ any person in suchImanner as to become subject to Workman's Compensation <br /> laws of California." <br /> ! I WILL CALL FORA GROUT INSPECTION PRIOR TO GROUTI-NG ANDA FINAL INSPECTION. <br /> SIGNE _ -- <br /> TITLE_:_ -- -DATE <br /> (DRAW PLOT ON REVERSE- SIDE <br /> R DEP RT ENT _ SE/ONLY <br /> -PHASE I <br /> 'APPLICATION ACCEPTED BY w¢ t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III^FINAL INSPECTION <br /> INSPECTION BY �, DATE � '� INS�ECTIfN rY (V DATE 2 JJ <br /> 9/78 2M <br /> EH 14 26 Rev. 9/78 <br />