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SAN JOAQUIN LOCAL HEALTH DISTRICT —OFFICEEQR USE: 1601 E. Hazel ton ,Ave. ,. Stockton-, CA 95205 Permit No.�g'� - <br /> Telephone: (209) 466-6781. <br /> Date Issued r 1� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires .l 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 /> Joaquin County Ordinance -No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. a E' GF fes : :2�1 •., � ss See, <br /> Ai <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Phone — <br /> Owner' s Name T ----- , --- Y <br /> Address. _ Ci ty <br /> Contractor's Name ' , License# Phone <br /> IS CERTIFICATE OF W0RKr1AN'`S COMPENSATION! IPJSURA'NCE ON FILE WITH SJLHD? YES +JO <br /> TYPE OF WORK (Check) : NEW TELL G7 DEEPEN ❑ RECONDITION~® DESTRUCTION❑ w ' <br /> WELL CHLORINATION C3 WELL ABANDONMENT 0 OTHER 0 AptPUMP INSTALLATION [p, PUMP REPAIR❑ PUMP REPLACEMENT <br /> hh 1 <br /> V <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY_ <br /> SEWAGE OIS:P_ OSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> .. PROPERTY LI-NE', PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 17 <br /> {INTENDED USE TYPEtOF'WELL CONSTRUCTION SPECIFICATIONS ' <br /> T-.dustrial. ' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled ; t ., Diwa:? of WelT� Casing w <br /> Domestic/publ-i c " ` _ � Dri ven Gauge of"Cas i rim <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: ;t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %State Work Done � da 30 <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL:' `Wel"1""DiameterApproximate Depth T <br /> --- �Descri be" Materi-al and Proce ure <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 employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL- INSPECTION. <br /> SIGNED TITLE: DATE: 17 <br /> RAW PLOT PL N ON REVERS S £ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTEb' BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTION770 PHASE TIT FINAL TNSPEC ION <br /> INSPECTION 6Y'' DATE INSPECTION B'��/ DATES .�/,7� <br /> __ __ e) <-- � 1./78 2M <br />