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a. "rte <br /> 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P�!FFICIE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.��_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3_,- -:�^ <br /> ('Complete 7 <br /> In ripli <br /> � y cate) <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 'Sah <br /> Joaquin County Ordinance No. 1862 and the Rules and- Regdlations of the San Joaquin local, Health <br /> District. <br /> EXACT STREET ADDRESS <br /> 2 CITY/TOWN Z d� <br /> Owner's Name Phone <br /> Address: Ds- <br /> V Ci ty_ _ <br /> Contractor's Named , pLicense# Phone` - 77 ,007'9 <br /> i! <br /> '.IS CERTIFICATE OF WOWIIAN'S COMPENSATION INSURAMCE ON FILE WITH-SJLHD? YES <br /> TYPE OF WORK (`Check) : NEW WELL Mr DEEPEN ❑ RECONDITION DESTRUCTION[) v <br /> WELL CHLORINATION 0:,WEEICABANDONMENT❑'=-OTHER f <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑' - RUMP. REPLACEMENT [:], <br /> DISTANCE TO NEAREST: ;SEPTIC TANK SEWER LINES____!! +�P,IT PRIVY <br /> SEWAGE DISPOSAL''` TELD CESSP4L/SEEP,4GE P OTHER <br /> .PROPERTY LINE - PRIVATE D MESTIC'Wt.L:L PUBLTC DOMESTIC WELD <br /> INTENDED USE TYPE OF-WELL.- CONSTRUCTION SP <br /> Industrial � � - SPECIFICATIONS <br /> 4 Cable Tool" Dia, of Well Excavation <br /> Domestic/private,; Drilled Dia. of Well Casing <br /> Domestic/pub? i c i Driven Gauge of Casing <br /> wl <br /> Irrigation �� Gravel Pack Depth of Grout S <br /> Cathodic Protection __, ,_Rotaryea <br /> Disposal Type of Grout <br /> ptOther <br />� `Geophysical ; Other Information <br /> 3 <br /> Surface Seal Installed UF <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H� <br /> PUMP REPLACEMENT: i, <br /> ���]State Work Done <br /> PUMP REPAIR: _ ❑State Work Done ' <br /> DESTRUCTION OF WELL: <br /> We71 DiameterTApproximate Depth l <br /> -- - <br /> Describe Materia anF rote ure „ _ -- _ _- r-.- <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 th,e 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.11 , <br />' I WILL CALL FOR A GROUTOINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> T L N ON REVERS�SIDE <br /> r Lt �C3/�f�9 - <br /> PHASE I FOR DEP RTMEN USE ONLY <br /> P,P� LICATION ACCEPTED BY. ... DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii G E!T I PEC ION PHASE III ' FINAL INSPECTION <br /> INSPECTION BY � �� DATE INSPECTION BY :-- . <br /> EH 14 26 Rev. 9./78 DATE • 20 -2j� <br />