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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FEICE, SE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. --& <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -1�� <br /> (Eomplete In Triplicate) <br /> F y <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 &OSSdM 8j?1Z*-E Oeff &rAK& SLfJ ff CITY/TOWN 7 fJOYTI1y ASE' <br /> "Ow6er's Name S. 3' Qk /C O kS ZW077 Phone 9�gg -.2.28/ _..._ <br /> Address __I.gl <br /> 0 6. 4Z,6Z f= City <br /> Contractor's Name &20jaf gLA7MggLicense#Pr y/ga' Phon 2 G <br /> IS` CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES '0< 0 <br /> TYPE OF WORK (Check) : NEW WELLS DEEPEN ❑ RECONDITION ❑ DESTRUCTION, d <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0­ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D URESTIC WELL <br /> INTENDED USE TYPE OF .WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation3`' - <br /> 17 Domestic/private.:. - Drilled-- --. = Dia.- of.Wel.l,.iCasing- <br /> u Domestic/public _Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea Fu// LB�� r <br /> Cathodic Protection yC Rotary Type of Grout Genn gnp-i <br /> Disposal Other Other InformaFion <br /> Geophysical Surface Seal Insta edby: 2r,9 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia` 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 /> ;Is <br /> ' I' certify that in the performance of the work for which this permit is issued, I shall <br /> not employ p y _an <br /> y person in such manner as to become subject to Workman's Compensation <br /> laws of California. '' <br /> � I WILL FOR A GRO INSPE TION P OR TO GROUTING AND A FINAL INSPECTION. <br /> ' SIGNE < TITLE: ss . ��/DG,E �1 DATE: -f-/6�9 <br /> D PLO N ON REVERSE SIDE i <br /> PHASE I R DEPARTMENT USE ONLY <br /> PPLTION ACCEPTED <br /> DATE 4/-'f6-7 <br /> ' I AADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -. DATE 5;,- 1 - " Y7 <br /> EH 14 26 Rev.-. 9/78 �� 9/78-,--2M-- <br />