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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 160-I.E. Hazelton Ave. ; - Stockton,. CA 95205 Permit No'•��` 3 <br /> ` - Telephone: (209) 466-6781 <br /> s Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires .1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Loca1'� 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 7 izr !I CITY/TOWN <br /> r O <br /> Owner's Name <br /> Phone <br /> C4 Ai� <br /> Address Z T !" �!� City. f1 <br /> Contractor's Name c,7!' G License Cfhone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I11, RAINCE'ON FILE WITH SJLHD? YES NO � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑. RECONDITION ❑ DESTRUCT ION In A : <br /> WELL CHLORINATION Q WELL'ABANDONMENT 0 OTHER 0 <br /> PUMP ,I NSTALLAT ION �]! PUMPF1REpAI R❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST:. SEPTIC. TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ? CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL k °fid CONSTRUCTION =SPECIFICATIONS <br /> Industrialable Taol Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection ` - Rotary Type of Grout <br /> Disposal Other � Other Information <br /> Geophysical , + Surface Seal Installed b <br /> ' :'I <br /> PUMP INSTALLATI.ON: . ',Contractor H.P. <br /> Type!of Pump i <br /> l PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: i ❑State Work Done <br /> h DESTRUCTION OF WELL: Wel 1" Diameter Approximate Depth <br /> Describe Materia an Proce ure ' <br /> f � <br /> I hereby certify that I have *prepared this application and that the work will be .done in accordanc <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'lfor 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 ofi California." \ , Ii!�-- <br /> I .WILL CALL' FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ' x TITLE: / r DATE: <br /> SIGNED - 7 <br /> (UKAW PLOT PL N `ON REVERS SIDE <br /> _Y FOR DEPARTMENT USE ONLY <br /> PHASE 1 4 <br /> APPLICATION ACCEPTED BY n�a. DATE <br /> ADDITIONAL COMMENTS: <br /> E PHASE II GROUT3INSP£CTION ' PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 'INSPECTI;ON BY "- DATE /�� ZA <br /> ru Id9A Roti, 19_77' —__..._ <br />