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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton,AV-9. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> X41 -aly APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued --� <br /> (complete In Tripl'i cafe) <br /> G� e2gc <br /> Application is hereby made to the San Joaquin Local Health District for a permit t� construct <br /> and/or install the work herein described. This application is made in compliance -with San, C <br /> Joaquin County Ordinanc6,0o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 'Di stri ct. a �" <br /> 39,6�47 � � <br /> EXACT STREET ADDRESS;r�Q ' �i�t _tea+ 'C ITY/TOWN <br /> Owner's Name Phone <br />, Address �x <br /> Contractor's NameVu License /'f Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOM INSUR 4!C£ ON FILE WITH SJLHD? YES Z NO <br /> TYPE OF WORK Check) : NEW WELL DEEPEN ❑ RECONDITION <br /> ( � [,� DESTRUCTION[� e <br /> J WELL-CHLOR NATION 0-- -WELL ABANDONMENT ❑ OTHER 0 <br /> �„, 1PP, INSTALLATION E1,--.PUMP,RUAI R❑ PUMP REPLACEMENT.❑ <br /> DISTANCE TO NEAREST: ; S�ERTI C.�IAN , SEkfER;LINE PIT PRIVY <br /> x . 'SiEWAGE DISP SAO L FIELD w ! GG SSP L/SEEPAGE PIT ---- OTHER--• <br /> P.;ROPERTY LIN D PRIVATEFD MESTIC WELL PUBLIC DOMESTIC WELL ------ <br /> INTENDED USE. I TYPE. OF .WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �� Cable Tool Dia.' of Well Excavation <br /> Domestic/private Drilled • ~ Dia. of Well Casing +v <br /> Domestic/public Driven Gauge of Casing <br /> _Irrigation , µ Gravel Pack Depth of Grout, Sea-T q 0 �--� <br /> Cathodic Protection Rotary Type of Grout k -- <br /> Disposal Other,.. ,. -._ Other Information <br /> Geophysical Surface Seal Installed +t-- <br /> PUMP INSTALLATION: , Cflntractor <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: P State,Work Done <br /> 4�: <br /> PUMP REPAIR: I❑State Work Done <br /> DESTRUCTION OF WELL., Well Diameter � � Approximate .Depth <br /> Dbscribe ,Materi.al and Proce ure , •. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin CountyOrdinances, State Laws, and Rules and Regulations of the San-Joaquin Local <br />.Health District. dome 04'ner or licensed agent' s signature certifies the following: <br /> "I certify. that' inthperformance of the work for which this permit is issued, I shall <br /> not employ any persoI in such manner as to become subject to Workman's Compensation <br /> laws of. California.1 <br /> I WILL CALL FORA,6ROINWECTION PRIOR TO GROUTING AND A"FINAL INSPECTION. <br /> SIGNED TITLE: Dq 944ATE: <br /> iM PLO N ON REVE I = <br /> i OR DEPARTMENT USE. ONLY <br />`PHASE fDATE <br /> - <br /> APPLICIITiON ACCEPTED BY , <br /> - �y <br /> ADDITIONAL /Lkl- <br /> COMMENTS: :i�. f . -_; _ <br /> s ---- --w�• -PHASE-° II' GROUT INSPECTION AHA II INSPECTION <br />.INSPECTION BY DATE INSPECTION BY DATE <br /> tEH. 14Y26 Rev. 9/78 In _. _ 9/78 2M J <br />