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SAN JOAQUIN LOCAL- HEALTH DISTRICT ---- - - <br /> OFFICE USE: 1601- E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 9. .a � <br /> ' Telephone: (209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S/-3-79 <br /> (tonplete, hn„Tri p.l'icate) .: <br /> A(Plication 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 /> EXACT STREET ADDRESS CITY/TOWN ,d >y .. <br /> Owner's Name Phone 9,4J- <br /> Address10 0 city J4� <br /> Contractor's Name License# � Phone <br /> � 6'(v_ <br /> tS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES 0 <br /> TYPE OF WORK (Check) : , NEW WELL 0 DEEPEN ❑ RECONDITION DESTRUCTION 0 <br /> WELL CHLORINATION [] WELL ABANDONMET 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPA R Lf' ,P REP CEMENT C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY (� <br /> SEWAGE DISPOSAL I E L D CESSPOOL/SEEPAGE PIT OTHER <br /> i x PROPERTY LINE - PRIVATE DOMESTIC WELL .- PUBLIC DOMESTIC WELL <br /> I INTENDED USE TYPE OF WELL.. CONSTRUCTION SPECIFICATIONS - <br /> industrial Cable Tool Dia, of Wel1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public . Driven Gauge of Casing <br /> 4 Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary t Type of Grout <br /> - <br /> Disposal Other Other Information <br /> Geophysical 'Surface Seal In-st-LTTed b <br /> PUMP INSTALLATION: K Contractort <br /> Type of Pump H, , <br /> PUMP REPLACEMENT: State Work Done _ - <br /> f 'PUMP REPAIR: Oystate Work Done - <br /> DESTRUCTION-OF-WELL: -We 11�'Diameter = - pproximate Depth-- <br /> Describe Material and Prode ure <br /> I hereby certify that I have Prepared this-a lication -and that the work will -be done in accordai <br /> with' San Joaquin County Ordinances, State Laws, and•'Rules and Regulations of the San Joaquin Loci <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 Californ-fa. " <br /> I WILL CALL FOR A.-GROUT INSPECTION PRIOR TO GROUTING AND A FINAL- INSPECTION. y <br /> SIGNED <br /> TITLE: DATE: 3- - . <br /> �a ? <br /> :(DRAW-.".P401,W .PLOT, L N ON REVERSE IDE <br /> s 'r r R�DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED.,BY>- . DATES-- 79.- <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT •INSPECTION ' PHASE III FINAL -INSPECTION <br /> ;INSPECTION BY DATE INSPECTION BY .DATE S` <br /> EB 14 26 Rev. 9/78 -- 9/7 29 <br />