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A © f3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: p, y• 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3�t� <br /> This Permit Ex ires 1 Year From Date Issued '1 ,41-1- / <br /> 7- <br /> Complete In Triplicate -7-& 27-/ 37 1 Mk.-4— <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 /> %'oao},yin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> ,istrict. <br /> EXACT .STREET ADDRESS Z2- 1 37 ,1, 69Ze.0 yrGrGAlp CITY/TOWN I't;Owner' s Name Phone - <br /> Address AM IF, City - - <br /> Contractor's Name �A A,1 License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IIISURANCE ON FILE WITH SJLHD? YES 040 <br /> TYPE OF WORK (Check) : NEW WELL E] DEEPEN 0 RECONDITION [1 DESTRUCTION[:) <br /> WELL CHLORINATION p WELL ABANDONMENT CJ OTHER F-3 Na <br /> PUMP INSTALLATION .' PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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 b W l,/ 6,[Z-- <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter AAAApproximate Depth T4!9 <br /> Describe Material and Procedure <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 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 41- <br /> TITLE: r � <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY E?;�� l�/17 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Z6 DATE <br /> EH 1426 Rev. 12-77 - - _- _ 1/78 2M <br />