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SAN JOAQUIN LOCAL HEALTH DISTRICT"FOR permit <br /> FFICE USE: /1601 E. Hazelton Ave. , Stockton, CA 95205L�11 <br /> Telephone:-J- (209) 466-6781 Date Issued 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip lcate <br /> 4gplication is hereby made to the San Joaquin Local Health District for a permi o construct <br /> ind/or install the work herein described. This application is made incomplianc ith San -- <br />'oaquin County Ordinance No. 1862 and the Rules and Regulations of ,the San Joaqu ocal Health <br /> District. <br /> CITY/TOW ! <br /> EXACT STREET ADDRESS Phone <br /> Owner's Name <br /> city <br /> Address <br /> Li cense# 3 fgg9 J� Phone <br /> Contractor's Name A&_n w.li�oM - ------ <br />'S CERTIFICATE OF WORKMAN'S C0111PENSATION INSURAINCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL LS DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER[] <br /> PUMP INSTALLATION [' PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY -� <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PITS OTHERCA <br />_ PROPERTY LINES?PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial � Cable Tool Dia. of Well Excavation_( <br /> Domestic/private Drilled Dia. of Well Casing "C2 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary . -Type of Grout q K Sa cern <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H' a' <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 accordant <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 o TITLE: njl <br /> DATE: aD 7 <br /> DR W PLOT PLAN ON REVERS IDE <br /> R DEPARTMENUSE ONLY <br /> PHASE I DATE 60— <br /> APPLICATION ACCEPTED BY ;7x�__ <br /> ADDITIONAL COMMENTS: <br /> P II OUT INSPECTION PHAS I INAL INSPECTION <br /> INSPECTION BY DATE —'\$ INSPECTION BY DATE - <br /> 1/78 2M <br /> � �7� <br /> FH 1 A?A RPv_ 12-77 _ <br />