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'SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> ( FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 5 <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 9 <br /> This Permit Ex fres 1 Year From Date Issued <br /> �. >Gomplete In Triplicate) <br /> �.' _ <br /> Application is hereby made to the"San *Joaquin! Local. Health- District for a permit to 'construc't <br /> and/or install the' work herein described, T•hi`s 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 ADDRESS741 err s bei <br /> , j �" CITY/TOWN <br /> o ! rl�ame � � - � � Phone <br /> Address Sb ,. ( , , O9~ - <br /> @ .. _.x�I : City <br /> C'ontractor's NamPpv <br /> €i cense#� Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 'VO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONiDITION J DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPA}R L PUMP REPLACEMENT El _ <br /> DISTANCE TO NEAREST: SEPTIC TANK ]- SEWER LINES --4 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> �cg_ CES—SPOOL—/SEEPAGE PIT� OTHER -- . <br /> PROPERTY LINE 'PRIVATE DOMESTIC WELLf 01 PUBLIC DOMESTIC WELL — - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialr t <br /> Gable- Tool .... ..--Dia-:---of-Wel-1-E_cca-va-ti-o r- <br /> Domestic/private i Drilled Dia. of WellCasing -� - �• <br /> Domestic/public Driven Gauge of Casing t� y . <br /> Irrigation = Gravel Pack Depth of Grdut Seal <br /> Cathodic Protection Rotary T ' <br /> Disposal �" Other Type of Grouter <br /> Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor �`` ' � } <br /> TLD <br /> Type of Pump Q— .P. , <br />'UMP REPLACEMENT: M-State Work Done . 41 <br />'UMP REPAIR: Q State Work Done Y <br />)ESTRUCTION OF WELL: Well Diameter _ �,-� -- - Approximate Depth <br /> Describe -Materia .. an- Procedure <br /> ure <br /> hereby certify that I have prepared this application and that the work will be done in accordance <br /> d th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth District. 'Home owner or licensed agent's signature certifies -the following: <br /> "I certify that in the performance of the work for which this 'permft"-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 /> WILL CALL OR A GUT A I SPECT' PRIOR: TO GROUTING-AND A_FINAL-, I;NSPEC_T,ION. <br /> IGNED. TITLE: - DATE: �Z , <br /> DR W PLOT L N ON REVS SES D <br /> HASE I FOR DEP RTMENT. USE ONLY � <br /> PPLICATION ACCEPTED BY <br /> DDITIQNAL COMMENTS: _ DATE- L- .r <br /> PHASE II GROUT INSPECTION f <br /> VSPECTION BY PHASE III FINAL- INSPECTION � <br /> DATE �y-moo 7:y INSPECTION BY DATE <br /> LIA26- _ RPv_ 12-77 - -- - <br />