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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7g <br /> Telephone: (209) 466-6781 <br /> ' Date Issued/ -/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> '('Complete 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 Sane` <br /> Joaquin County Ordinance No: 1862 and the Rulesan� Reg a ions of .the San-�Joa uin Local Health <br /> District. /UtOTG--�I s'/ 3 5' CC� <br /> EXACT STREET ADD E55 �� ��`rt �- 5�� CITY/TOWN <br /> Owner's Name AelvYlQ ejo�,J,s Phone <br /> Address `. - 4 City _ <br /> 4-Y , <br /> Contractor's Name-Rear/me .v Li cense�7� Phone /—�2-/0- <br /> IS CERTIFICATE OF WORKMAN'S CO"iPENSATION INSU "10E ON FILE VII-TH-ItSJLHD? YES 0 _5 <br /> 1 TYPE OF WORK (Check) : NEW WELL Vj,� DEEPEN ❑ RECONDITION -, DESTRUCTION[] �� r <br /> WELL' CHLORINATION Q WELL ABANDONMENT 0� -OTHERFJ v+ <br /> i _ PUMP .INSTALLATION M--PUMP REPAIR p ':PUMP REPLACEMENT-Q <br /> ! DISTANCE TO NEAREST: SEPTIC TANKQ SEWER LINES w PTT PRIVY <br /> SEWAGE DISPOSAL IELDSSP OL/SEE .AGE PIT- OTHER <br /> PROPERTY LIN50`TPRIVATE DOMESTIC WELL IPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Excavation s2 <br /> Domestic/private Drilled Dia. of Well"-Casing <br /> Domestic/publicy6riven Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic rt-- <br /> Protection —Other- <br /> Type of Grout ' <br /> Disposal Other Other Information <br /> - - : Geophysical Surface Seal Installed b <br /> PUMP- INSTALLATION: Contractor24&4-9 d 7Is <br /> Type of Pump , " H. <br /> PUMP REPLACEMENT: M State Work Done <br /> - aE <br /> PUMP REPAIR. (State Work Done ' <br /> ` DESTRUCTION OF WELL: Well Diameter Approximate Depths K <br /> Describe Materia an Proce ure , <br /> I hereby certify that I have prepared. this application and that the work will bedone.-in accord c <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 ,F <br /> not employ any person in such manner as to become. subject to Workman's-tompensatian <br /> laws of California. <br /> I WILL CALL FOR .A GROUT .INSPECTION PRIOR TO GROUTING AND A"F NAL 'INSPECTION, ' <br /> SIGNED TITLE: DATE: ! I _Z-)1'1/,17F <br /> DR N ON REVERSE/SIDE) Jf� <br /> / OR DEPARTMENT JJSE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY � < DATE 7 Pr <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE_�_ �q INSPECTION BYDATE /-L 3 -fib <br /> EH 14 26 Rev. 9/78 .9/7f3,. 2M- <br />