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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave, , Stockton, CA 95205 Permit No.?tea <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issueds-/-79 <br /> (Comp l.ete _I n Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to co02t <br /> and/or install the -work herein described. This application i.s-.made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> District. I ji-tVo 54 <br /> n . <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name /% Phone <br /> Address _ � � ��—�9'��' <br /> E S Ci.ty:: <br /> Contractor's Name ; License# 3 , Phone, <br /> I5 CERTIFICATE OF WORK"AN'S COMPENSATION INSURANCE ON FILE 'WITH-SJLHD? YES 1"` No <br /> TYPE`OF WORK ecDEEPEN ❑ RECONDITION ® DESTRUCTION O <br /> WELL CHLORINATION [3 'WELL ABANDONMENT p OTHER n _ . <br /> PUMP INSTALLATION 'M PUMP REPAIRED PUMP REPLACEMENT E3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSP OL/SEEPAGE P � - OTHER <br /> - PROPERTY LINE - PRIVATE DOMESTIC WELL_.____ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF .WELL.. <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavaition <br /> Domestic/private Drilled Dia, of Well Casing n <br /> Domestic/public Driven Gauge of Casing=Ir ¢ <br /> arigation - _ Gravel Pack Depth of Grout Sea <br /> thodic Protection " 4-7 Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical , �'� Surface Sea] Insta ed b : <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: Wel 1 .Diamete �,. <br /> r �,, .;:. - . ''.Appr-oximate.\Depth <br /> - z- Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application an.d that the work' will be done in accordant <br /> With San Joaquin Caun1ty Ordinances , State Laws , and Rules and Regulations of the ..San Joaquin ;focal <br /> ;Heal t}`,Di st'ri ct Horne owner or 1 i tensed agent' s signature certifies the 'fol l-owi ng: <br /> "I certify that in the performance of the work -for which t.his, permit is issued, , I shall <br /> not`'em 10 an <br /> P y y person in such manner as to become subject to Workman's Compensation <br /> laws" of California. " <br /> WILL CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:� , <br /> (DRTW. PL T PUN ONtREVERSE —" <br /> PHASE I OR DEP RTMENT USE ONLY <br /> f � <br /> APPLICATION ACCEPTED BY ' DATE / 1-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. rAt <br /> I?NSPECTION BY �, . PHA I N INSPECTION <br /> DATE INSPECTION B DATE Sz/--�y <br /> EH\,�14 26 Rev. 9/78 <br /> 9/78 - 2M <br />