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r SAN 4JOAQUIN LOCAL HEALTH DISTRICT ---- <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No- I;11 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . <br /> Date Issued -,?CZ . <br /> (Eomp l ete I n TO p,,l i cafe) , <br /> t <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" Reguiations of'the San Joaquin Local Health <br /> District. <br /> E <br /> EXACT-STREET DRESS - CITY/TOWI�e� �C�- � : _ <br /> Owner's Name Phone <br /> Address _ City... <br /> Contractor's Names License Phone <br /> IS CERTIFICATE OF WORKMAN'S -COMPENSATION IN RA"lCE- ON FILE WITH-SJLHD? -- YES NO. <br /> TYPE OF WORK (Check) : NEW WELL, § DEEPEN Q RECONDITION [:] , DESTRUCTION.[�� _ {, <br /> _ W.EL'L-CHLOR-1-NATION-0----WELL PiBANDONMENT0`�THER.o <br /> PUMP INSTALLATION 4Z PUMP. REPAIR 0 ',-PUMP REPLACEMENT.C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK-`6fSEWER LINES 69 -- <br /> _ FIT_P_R_I VY-- <br /> - •-SEWAGIE-DIS-P IELD CESSP OL/SEEPAGE PIT 6 HER <br /> PROPERTY, LIN -PRIVATE DOMESTIC WELL PUBL�ESTI.C.-WELL <br /> INTENDED USE, TYPE OF-WELL._ , CONSTRUCTI.ON, SPECIFICATIONS <br /> Industrial i s Cablejool Dia. of Wel Excavation (- <br /> t�iDomesti c/pri vate l;l ed Dia. of Well Casing �o <br /> Domestic/public Driven. Gauge of Casing '.®6s :• 1_1Ay�=__ <br /> Irrigation Gravel -Pack Depth of Grout Seal <br /> Cathodic Protection - btary x Type of Grout <br /> w <br /> —"7'—Disposal Other;— Other Information <br /> Geophysical s -� Surface S 1 Installed b <br /> PUMP INSTALLATION: Contr`actor._ <br /> I � Type `of Pump %1 a H.P. <br /> PUMP REPLACEMENT: -- �]yState Work'Done <br /> PUMP REPAIR: ❑State Work Done ti - <br /> DESTRUCTION OF WELL: Well Diameter pproximate Depth <br /> 'Describe Material and Pro a ure <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 Locale <br />� H;ealt'h 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`ito Wprkman's Compensation _ <br /> laws of California. <br /> rI WILL CALL F R A GROUT INSPECTION PRIOR TO GROUTING ANDA NAL INSPECTION. <br /> SOIGNE a TITLE: DATE: <br /> '-RAW PLOT PLAN ON REVERS SIDE <br /> ZDEPARTMENT USE ONLY <br /> PHASE I g <br /> PPLICATION ACCEPTED BYE... DATE 3 a4�_ <br /> ADDITIONAL -COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> -INSPECTION' BY QL DATES 4 1 \ INSPECTION BY r DATE <br /> ,.-�-� <br /> tEH 1:4, 26 Rev. 9—%78 9.. � . � _.. <br />