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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t E.FICE�-USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. . <br /> __7Telephone: `�� <br /> (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,,-?.LL-2f <br /> (,Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constr ct <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. C,47/003 14 rCg �w <br /> EXACT STREET ADDRESS9/4/4 S ,� CITY/TOWN_�„, oJ�►o.> <br /> Owner's Name__,2r 4, j DAPhone -- <br /> Address <br /> Ci tyAze <br /> �,/�, <br /> Contractor's Name " <br /> ff <br /> ✓ca Licensed Phone _ -- <br /> IS CERTIFICATE OF WORK�IRN'�S COM NSATIOP4 INSURA"!CQN FILE' WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) NEWWELL b DEEPEN ❑ RECONDITION ( _ DESTRUCTI.ON d N <br /> PUMP INSTALLATION CT`` ''RUMP'REPLACEMENT' `'V; <br /> DISTANCE TO NEAREST: ' SEPTIC TANK u a f SEWER LINES PIT PRIVY _� <br /> SEWAGE DISP05AL IELD CESSP L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE -TYPE OF -WELL.., CONSTRUCTION SPECIFICATIONS <br /> _Industrial - Cable —Tool Dia. of Well Excavation - <br /> �.�Domestic/private Drilled pia, of Well Casing . <br /> _Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> „A Cathodic Protection Rotary Type of Grout <br /> Disposal - <br /> E _ Other Information Other�eophysical a <br /> Surface Seal Insta ed <br /> PUMP INSTALLATION: ;" Contractor 14J.-Vnd cd <br /> L � <br /> Type of Pump <br /> HT. <br /> PUMP REPLACEMENT: 'SC].State Work Done <br /> :_LUMP REPAIR: `*f OState Work Done <br /> DESTRUCTION OF WELL: Ael Diameter <br /> Describe MateriaT and Procedure Approximate Depth ¢ <br /> I hereby certify that I have prepared this =application and that the work will <br /> ice <br /> With San Joaquin County Ordinances , State Laws, and Rules and Regulations of the Sanbe eJoaquinin oLo nil <br /> Health District. Home owne,`r or licensed agent.'s si.gnatu.re---ce.rtafi-es--the-.fol-l-owi-ng-: <br /> "I certify vthat i'n-the- --pe—r.,formanEe.of thewor.k�for-who-ch-this-permi-t-i-s—is'sued—I`SKi 1-1T <br /> 6ot'employ any person 'in such-ymanner' as. to becomessubject to Workman's Compensation ' <br /> laws of California. <br /> I WILL CALL _FOR.A GRO T INSPECTION PRIOR TO GROUTING AND AFINAL INSPECTION. <br /> SIGNED <br /> TITLEi DATE: ` <br /> R W PLT L ON REVS SE SIDE <br /> PHASE I F R DEP RTMEN USE ONLY <br /> PPL CCATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION zy PHA I F SPECTION' <br /> INSPECTION BY DATE. INSPECTION BY <br /> EH 14 26 Rev. 9/78 DATE r-" <br /> _9_/7_8 2N! <br />