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SAN JOAQUIN LOCAL: HEALTH-DISTRICT <br /> FOR FFItE USE: ' 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7q`5Qr1.. -, <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR 'PUMP PERMIT Date Issued <br /> (Complete In' Triplicate)' <br /> Application ­is hereby made to the San Joaquin Local -HealthiDistrict for a permit to construct . <br /> and/or install. the work herein described. This application is made in compliance with San <br /> Joaquin Ciounty Ordinance No. 1862 the Rules and Regdl ons of -the San Joaquin Local Health <br /> District. ; <br /> EXACT STREET AD S " � `'.� CITY/T <br /> Owner's Name -�l� Phone f <br />'j Addressrz City <br /> Contractor's NameLicense#/ �37� Phone <br /> I5 CERTIF,�ICATE,.OF WORKir1AN'S CO";PENSATIOr! IPJSURA"dCE ON FILE WiTH SJLHD? YES �� 0 <br /> �TYPE�OF ic <br /> WORK, (Check) : NEW WELL C) DEEPEN ❑ RECONDITI'ON (2, DESTRUCTION[ <br /> WELL CHLORINATION (D WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR[""PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE ,PiT OTHER <br /> {f f:PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL.: CONSTRUCTION SPECIFICATIONS <br /> industrial H Cable Tool Dia. of Well Excavation 44 <br /> r Do''mestic/private Drilled Dia. of Well Casing <br /> Domestic/public'. Driven Gauge of Casing_ <br /> Irrigation G avel P Depth of Grout Sea ' <br /> Cathodic Protection taFy\ Type of Grout n u. <br /> r Disposalrcher Other Informat� n <br /> + Geophysical ,. Surface Seal s e b <br /> PUMP INSTALLATION: : Contract r <br /> l• Type of P <br /> PUMP 'REP <br /> _ LACEMENT: '� �]State Wo Done <br /> PUMP :REPAIR: Mate Work 'Dane x <br /> t—DESTRUETI0l -.'OF--WELWeTI Di.amete.r�,� - Apprroxtei:,ma.t_.e fe`pt_ h- <br /> ' <br /> ­ <br /> "I' Describe . <br /> Materia and Procedure <br /> r � _ <br /> I hereby certify that I have prepared this application and that the work- will be done in accordar <br /> with-San Joaquin County Ordinances , State Laws," and Rules and Regulations of the San Joaquin Loci <br /> Health District. Home!i-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 e�ploy 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: -w DATE:" <br /> 7r <br /> (DRAW PLOT PLTN ON REVERSE SIDE - <br /> 36 <br /> FOR D P R MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /�,Zm� DATE C� <br /> ADDITIONAL COMMENTS: - !I' <br /> PHASE. II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIONI BY DATE INSPECTION BY DATE <br /> IEH 14 26 Lv: 9/78 9/78 M <br />