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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LEOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7q- 6 I/ <br /> X1 I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITDate Issued ! 7P-�� -�- <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. <br /> EXACT STREET ADDRESS 746 aS. Wim. CITY/TOWNVA44(c ... <br /> Owner's Name R. 6, Af a- d,p Phone <br /> Address Z .. City <br /> Contractor's Name Licensetzzc,73Phoney-35« <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION Q DESTRUCTION Cl <br /> WELL CHLORINATION Q WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION a PUMP REPAIR 0 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISP S�AL -IELD CESSP L/SEEPAGE PST— OTHER �l <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLITTURESTIC WEA- J <br /> INTENDED USE TYPE OF WELL_., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> r X..._Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> F----- <br /> Disposal Other Other Information <br /> r Geophysical Surface Seal Installed y: <br /> RUMP INSTALLATION: Contractor s <br /> Type of Pump <_J6 M Q ., 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 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 GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:-� � �-, -- <br /> (DRAWPLT PLAWON REVERSES E <br /> R DFPAR M--- NT USE ONLY <br /> PHASE I <br /> Pf�LICATION ACCEPTED BY /t.Y.a,,. DATE ZI7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> EH 14 26 Rev. 9/78 9/78 <br />