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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICEFOR USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No. 7-a('-/-/,' <br /> J✓� <br /> Telephone: (209) 466-6781 pate IssuedL;/L <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT <br /> Th.is .Permit Ex ires I Year From -Date Issued <br /> Complete. In Triplicate <br /> Aoplication 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 /> CITY/TOWN <br /> EXACT STREET ADDRESS 5 q .� - f�� �L Gly <br /> , _ <br /> r . Phone <br /> Owner' s Nance <br /> Address r City <br /> Contractor License# Phone Name S'e — ' <br /> IS CERTT FI CIITE OF WORKiIAN'S CO"IPENSATIO"! 111SURA^fCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK :"(Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [D DESTRUCTION F1 N <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER ❑ <br /> t <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT' W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY v� <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 Industrial Cable Tool Dia. of Well Excavation <br /> �{Damestic/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 <br /> Geophysical LL Surface`5ea1 Installed b <br /> PUMP INSTALLATION: Contractor P r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �lt�a proxito Depth <br /> Describe Materia -and,�Procedure ° <br /> iJ <br /> I hereby certify that I have prepared this application and thatthe work will be done in accordant <br /> with San Joaquin County Ord:inances,,_State Laws ; and Rules and`. Regulations of the San Joaquin Local <br /> Health District. Nome owner or li'censed-�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 sub_je'ct to Workman' s Compensation <br /> laws of Cal i-forn'i-a. <br /> I WILL CALL FOR A- GROff-INSPECTIONePRIOR TO. GROUTING AND A FINAL INSPECTION. ` <br /> SIGNED � " FTITLE: -1 DATE: s 7� <br /> DR W PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY �r <br /> PHASE IDATE. S <br /> APPLICATION ACCEPTED BY IIQ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT !INSPEC ON PHASE III FINA INSPECTION <br /> INSPECTION 8Y DATE INSPECTION BY DATEccs <br /> 7 <br /> �. 117 8 2M11 <br /> CU 1 A9f, Mau 19-77 <br />