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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ?q-sel <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I Date Issuedb-6-lq <br /> g,SD 60 _ (,Complete In Triplicate) 071`�� <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 San <br /> Joaquin County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSpiT1� l t� L CITY/TOWN-403)1 , <br /> Owner's Name 12N Phone6 o92,3 -L177. T <br /> Address Ci ty �� Cho _ <br /> Contractor's Name a <br /> �-o2 . Li cense# Phone(30�)571-I Ijj�j. <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"!CE ON FILE WITH SJLHD? YES ✓ 0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION d, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 50 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT =,] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP- OTL/SEEPAGE PIT OTHER ) <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELD -A <br /> INTENDED USE TYPE OF 1iole . CONSTRUCTION SPECIFICATIONS + <br /> .Industrial Cable Tool Dia. of Well Excavation , <br /> Domestic/private Drilled Dia. of Well Casing _ lyr�n e• <br /> _____ Domestic/public Driven Gauge of Casing N e-, <br /> Irrigation Gravel Pack Depth of Grout Seal N o n e. INA <br /> Cathodic Protection - Rotary Type of Grout '- <br /> Disposal Other Other Information o'- ISS <br /> 7' Geophysical Surface Seal Insta by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump —H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 2• �� A <br /> Describe Materia and Procedure 1 Approximate Depth to' -15" <br /> I hereby certify that I have prepare 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 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 ifornia. " <br /> I WILL C 0 A GRO SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED A TITLE: DATE: 6 06 . <br /> DR W PLOT L N ON REVERSE SIDE <br /> PHASE I FOR D PARTMENT USE ONLY <br /> TP-PLICATION ACCEPTEDCg2� <br /> _ cc .e <br /> ADDITIONAL COMMENTS : DATE <br /> PHASE II GROUT INSPECTION PHASE III 'F'INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYATE <br /> EH 14 26 Rev. 9/78 9/78 2M <br />