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_ 4", SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. b7? <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Date Issued 7- -7 <br /> (Complete In Triplicate) k <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or, instal'; the work herein described. This application is made. in compliance with San j <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health j <br /> District. 1 <br /> EXACT STREET ADDRESS fs'� 8s u.. CITY/TOWN Ala n 4 <br /> Owner's Name "'" "Y-. tee, ' Phone <br /> Address / °' City . <br /> Contractor' s Name&4v,,2License# 4 i,,, Phone <br /> IS CERTIFICATE OF WORK'1AN'S CO111PE1 TI 'N vAINSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN'O RECONDITION Q DESTRUCTION( <br /> WELL CHLORINATION 0 WELL ABANDONMENT C OTHER(. <br /> .PUMP INSTALLATION Q PUMP REPAIR 09 PUMP REPLACEMENT Q <br /> 6ISTAN_CE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ✓1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL — , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigat ion-.". °. ,`.. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: 0 State Work Done - <br /> PUMP REPATR _(gState Work Done <br /> : DESTRUCTION OF WELL: Well Diameter Approximate Depth . <br /> Describe Material and Procedure <br /> I her certify that I have prepared this application and that the work will be done- in accordant <br /> with San Joaquin County Ordinances , State Laws , andRules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: n � <br /> "I certify that in the performance of the work for which this permit is issued, L shall <br /> not employ any person in such manner as to become subject to Workman's Compensation j <br /> laws of California . " <br /> I WILL CALL FORA GROUT INSP IO IOR TO- GROUTING AND A FINAL INSPECTION. <br /> SIGNE `�' ITLE:� DATE: <br /> 74 A4RA PLOT PL `-ON REVERSE S D m <br /> FOR D PARTM- T USE ONLY <br /> PHASE 1 <br /> APp.LICATION ACCEPTED BY DATE_Z 9 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N '. <br /> INSPECTION BY DATE INSPECTION BY DATE) <br /> EH 14 26 Rev.. 9/785/79 ^tip 2M <br />