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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 9- �2 -5 <br /> Telephone: (209) 466-6781 <br /> Date Issued 3-12-X? <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> ' <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 (WNE AVE C• a� t e 4» CITY/TOWN S�ocVAoh <br /> Owner's Name AL Z, Phone Cl-m- t-13�"' <br /> Address_ 101 ALkkto City �����.�o� <br /> Contractor's Name �?tlra_ru►�S_ ,sc�s nr \��� C� ��� Li cense#�,— Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> rTYPE OF WORK (Check) : NEW WELLLN DEEPEN ❑ RECONDITION Q DESTRUCTION(�] <br /> WELL CHLORINATION [] WELL ABANDONMENT 0 OTHER 0 ------ <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT Q �+ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPDS-ATTIELD CESS SOL/SEEPAGE PIS— OTHER <br /> PROPERTY LINE - PRIVATE DO WELL PUBLI -DWESTIC 4�ETC-- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We Excavation 11 = <br /> X Domestic/private Drilled Dia. of Well Casing I, - <br /> Domestic/public <br /> Domestic/public Driven Gauge of Casing t 4�1 <br /> Irrigation k Gravel Pack Depth of Grout Sea _ <br /> Cathodic Protection A Rotary Type of Grout <br /> Disposal Other Other Information So <br /> eophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H• <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q 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." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNS TITLE: DATE: <br /> PLOT PLVN ON REVERSE SIDE) <br /> DEPARTM ENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED B�/�� .� � �� DATE <br /> ADDITIONAL COMMENTS: <br /> PHME II OUT INSPECTION PHA I NAL INSPECTION <br /> INSPECTION BYDATE �j IZ-20 INSPECTION DATE - <br /> EH 14 26 Rev. 9/78 9/78 ;M <br />