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_ _ _ _ _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: <br /> 1601 E. Hazelton Ave, , Stockton, CA 95205 Permit No. <br /> Telephone:= (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued to-5-71'9 <br /> (tom� plete In Triplicate) ; <br /> Application is hereby � <br /> 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- cdmpliance with San <br /> Joaquin County Ordinan . <br /> District. e No. .1862 and the Rules and Regulations of the San Joaquin Local Health <br /> �I' - , <br /> EXACT STREET. ADDRESS <br /> CITY/TOWN <br /> Owner's Name Phone 3 Zb <br /> Address �E f City <br /> Contractor's Name License hon :J` <br /> 4 13 <br /> f <br /> IS CERTIFICATE OF WORKPiZAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD?. YES . BO <br /> TYPE OF WORK (Check) : NEW WELL L�` DEEPEN C] RECONDITION DESTRUCTION a <br /> WELL CHLORINATION WELL ABANDONMENT ® OTHER'O <br /> k :PUMP- INSTALLATION PUMP REPAIR d. PUMP REPLACEMENT Q Q3 <br /> M . <br /> DISTANCE TO NEAREST: USEPTIC TANK SEWER L.INES . � PIT PRIVY <br /> ' SEWAGE-DISPOSAL IELD CFSSPOL%S PAGE-FIT _ OTHER <br /> LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF' WELL.. i CONSTRUCTION SPECIFICATIONS <br /> Indust,raaT- Cable Tool Dia. of We 1 Excavation Icn <br /> Domestic/.prr,ivate- _Drilled Dia. of Well Casing_ — <br /> Domestic/:public Driven Gauge of Casing <br /> _ <br /> Ir ri gain on '� _ �, ; ravel Pack D F" <br /> Cathodic Protection ` - Rotary Depth of Grout Sea <br /> Disposal Type of Grout <br /> .Disposal Informat7on <br /> `.Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> p H.P. <br /> PUMP REPLACEMENT: []State Work Done _ <br /> PUMP REPAIR: �,hStat_e Work Done <br /> 11 <br /> DESTRUCTION OF WELL: W. ,ell Diameter <br /> , Approximate Depth _--- <br /> Describe Material and Procedure <br /> I hereby certifythat I k <br /> � ave prepared this application and that the work will be done in accordancl <br /> with San Joaquin County 'Ordinances , State Laws , and Rules and Regulations of the San ..Joaquin Local <br /> Health District, Home owner br 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' shail <br /> not employ',;'an <br /> y person in such manner as to become subject to Workman 's Compensation <br /> laws of Cal i Porn i a. <br /> II WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED d� r <br /> TITLE: . DATE: <br /> It DR PL T PL N ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY . <br /> PHASE I - , <br /> APPLICATION ACCEPTED BY � � DATE 5 —3e— <br /> ADDITIONAL COMMENTS: 7 <br /> PHASE II G QQT. INSPE ION • " 'PHASE III FINAL INSPECTION <br /> INSPECTION BY NDATE S� INSPECTION SY <br /> EH 14 26 Rev. 9 $ I� r DATE , /3- , r <br /> 7 X9/78 M <br />