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SAN .1OAQUIN LOCAL HEALTH DISTRICT" <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Zg!3 96 <br /> T(�lephone: (209) 466-6781 <br /> — ---� APPLICATION 50R WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 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 /> land/or install the work herein described. This application is made in compliance with San <br />° ,oanuin County Ordinance ^o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> FDistr�ct. <br />! EXACT STREET ADDRESS CITY/TOWN '? <br /> Owner's Name - ? e �oGt� Phone <br /> Address 3 5- <br /> 4R. city A, <br /> Contractor' s Name L }k( 4- (�az,�,� �,��; �[,Ti License Phone <br /> IS CERTIFICATE OF WORKMAN'S COM PENSATIOIN INSURAINCE ON FILE WITH SJLHD? YES �` 1,40 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] , <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION [9' PUMP REPAIRE] PUMP REPLACEMENT F] <br /> DISTANCE TO NEAREST: SEPTIC TANK e; SEWER ,LI, ES PIT PRIVY <br /> SEWAGE DISP SAL FIELD `' ? E PIT OTHER <br /> PROPERTY LINE -. PRIVAT WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing_ __ <br /> Irrigation Gravel Pack Depth of Grout Seal-----'� r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed'"b <br /> PUMP INSTALLATION: Contractor r. <br /> Type of Pump 4:u.. Ll H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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. " .4, <br /> I WILL OR GR UT INSPE TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 5IGNE TITLE: ' __ DATE: �" It-�'� _ <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />)HAS E I <br /> APPLICATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE—,//— 2 9-- 2 INSPECTION BY�� DATE <br /> �� 1/78 `/2M <br />'H 1426 Rev, 12-77 <br />