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SAN JOA QUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No.,2,X 5� <br /> Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/a //-78' <br /> This Permit Expires 1 Year From Date Issued <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 San <br /> ,'oanuin County Ordinance No. 1862 and the Rules- and Regulations of the San Joaquin Local Health <br /> DiStr;ct. ,� / fci�fc�vr4- <br /> EXACT STREET ADDRESS1 ^,/4urti# CITY/TOWN <br /> Owner's Name Do" a. e.,lz r) Phone ,�f —e)Z._�, <br /> Address �' �_ �rr., _�._ _ City,[ -- <br /> Contractor's NameLz& ,00eA,( o ,/' License#,26f 61 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO11 INSURAINCE' Orl FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION 9�- PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER rn <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information �k <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor aevivo Xy",4 " A-- <br /> Type of Pump aL H.P. <br /> PUMP REPLACEMENT: O State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accorda e <br /> with San Joaquin County Ordinances , State laws , and Rules and Regulations of the San Joaquin Loc 1 <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 California. " <br /> I WILL CALL FOR A G OUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED .•�� TITLE:�44DATE: a / <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED FYATE 1,2 //Z42 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION:- PHASF)IIL12K INSPECTION <br /> INSPECTION BY DATE INSPECTION B z DATE <br />�-H 1426 Rev. 12-77 1 /78 2M <br />