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SAN JOAQUIN LOCALHtALIH UISlir{luI <br /> FFICE USE: 1601 E. Hazelton Ave. ,IStockton, CA 95205 Permit N .19-7 <br /> Telephone: � _(209) `466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued '7 -7 <br /> This, Perm?t >_x i'res 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 /> Viand/or irnstall - the work herein described: This application is made in compliance with San <br /> 'oanuin 'County Ordinance pyo. 1862 and the .Rules and Regulations of the San Joaquin Local Health <br />, GiStr;�t. <br /> EXACT STREET ADDRESS CITY/TOWN f <br /> Owner's Nam r �� } <br /> .�- Lel � Phone <br /> Address Ci ty,�, C �'Uf <br /> Contractor' s Nam ' � 1 � <br /> �'cJ7�-�? L.i tens yJ--94- Phone. . <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 111SURANCE ON FILE WITS! SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 'DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION( ELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I dustrial Cable Tool Dia. of Well Excavation <br />!� omestic/private Drilled. Dia. of Well Casing` <br /> Domestic/public Driven Gauge-of Casing .r <br /> Irrigation i Gravel Pack Depth .of Grout -Seal--- - <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical rface Seal nstalled by: <br /> PUMP INSTALLATION: Contractor <br /> 4 Type ofi Pump H.P. <br /> k t <br /> PUMP REPLACEMENT: p State Work Done /- <br />, PUMP REPAIR: ,` ❑State Work Done ; <br />',DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />' I hereby certify that I have prepared 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 emplo any person in such manner as to become subject to Workman's Compensation <br /> k laws of alifornia. " <br /> I WILL CAL OR A SROJJT INSPECTRIOR GROUTING ANDAL INAL INSPECTION. <br />,SIGNED TITLE DAT '�i�'/ L� <br /> - DRATr PLUT PLAN ON REVERSE SIDE <br /> FOR DEP RTM NT USE ONLY <br />,PHASE I <br />'APPLICATION ACCEPTED BY DATE / ' <br /> ADDITIONAL COMMENTS: <br /> PHA II gROUT INSPECTION PHASE JII FINAL INSPECTION <br /> INSPECTION BY DATE.7911, T� INSPECTION BY DATE <br /> r <br /> EH 1426 Rev-" 12_77. ,, - . 7A - 9M <br />