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gFICE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: 1601 E. Hazelton. Ave. , Stockton', CA 95205 Permit No-7 9- y g D <br /> Telephone; (209) - 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-5-/6-?1), <br /> '("Complete In Tripl'icate). <br /> •- k: <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 Rulesand Regulations of the -San Joaquin Local Health <br /> District. . <br /> EXACT STREET ADDRESS j) <br /> da i�t CITi'/TOWNr� <br /> Owner's Name Phone , o <br /> Address — �— <br /> Contractor's Name License# /w37�.-,��phone „�� �?G�� <br /> _ <br /> IS CERTIFICATE -OF WORKIIIAN'S C �4P NSATION INSURANCE' ON FILE WITH SJLHD? YES �, NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN C7- y RECONDITION DESTRUCTION . <br /> - .— <br /> WELL CHLORINATION,] WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT [J <br />; .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> rPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT w OTHER <br /> PROPERTY- LINE- - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WE <br /> LL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> Drilled-r" Dia. of We11 Casing <br /> Domestic/public DrivenGauge of Casing <br /> Y RIrrigation - r Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ' Other .Information J ~ <br /> . .Geophysical - -� Surface Seal Inst a ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump : <br /> H.P . .:�- <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia an Proce ure pProximate Depth <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 Regulationsdf-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 INSPECT TO GROUTING AND A'FINAL INSPECTION.. <br /> SIGNED TLE: <br /> PL L ON REVERSE SIDE ---- DATE: �d <br /> PHASE I OR DEP TMEN USE ONLY F <br /> PP�- LICATION ACCEPTED BY " DATE i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION .BY DATE INSPECTION BY <br /> EH 14.. 26 Rev,. 9/78 DATE -/-7 <br /> F <br />