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aSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601� , .�Hazei,ton Ave. , Stockton, CA 95205 Permit No. <br /> "`fed <br /> rephone: (209) 466-6781 <br /> P .51 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued,5-;2- -? <br /> Y (Cotnplete.In Triplicate) , <br /> Application- is hereby made to the San Joaquin. Local Health District fora permit to construct <br /> and/or install the work herein described.. This, ap,plication, is made in compliance with San <br /> Joaquin `C'ounty Ordinance No. 1862 and the Rules. and Regulations of the San Joaquin L6cal Health <br /> District. ' <br /> EXACT STREET ADDRESS N s CITY/TOWN <br /> Owner's Name � - <br /> helkPhone(�,���� 3�� <br /> Address <br /> R F S E Ci ty-eaa CSIo _ <br /> Contractor' s Name License# Phan <br /> IS CERTIFICATE 'OF WORKMAN'S COMPENSATION INSURAINCE ON FILE' WITH SJLHD? YES No <br /> TYPE OF -WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ® DESTRUCTION[� „... <br /> • <br /> WELL- CHLORINATION 0WELL- ABANDONMENT Q OTHER M S 'i< <br /> PUMP INSTALLATION 'M PUMP REPAIR 0, - PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY w o� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -� <br /> a <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> - INTENDED USE TYPE OF-WELL; CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well ExcavationIg <br /> Domestic/private Drilled Dia. of Well Casing - �0 m.r=1 --T <br /> Domestic/public _ Driven. Gaugeaf�Casinc� <br /> Irrigation avel 'Pack Depth of Grout Sea A n A ICA ' � --�- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. . Other Other Information <br /> _Geophysical Surface Seal Insta d b <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. <br /> PUMP REPEACEMENT: _ E]State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELLA: Well Diameter `� pproximate Depth�sp' ,• <br /> } - � Describe Materia and 1PrbcedureC,,,,p <br /> f <br /> I 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 /> E "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 Cali rnia. ” <br /> I WILL CAL R A GROUT I SP TION PRIOR TO GROUTING AND A FINAL INS ECTION. <br /> SIGNED TITLE: DATE: Z. /7c), <br /> LO L N ON REVERSE SIDE <br /> PHASE I FOR P RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -_X, <br /> ADDITIONAL COMMENTS: DATE . <br /> PHASE II T INSPECTION - PHASE III FINAL INS ECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> EH 14 26 Rev. 8 DATE G 2y� <br /> _.�. • 9/78 2M <br />