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sloif!� `� SAN JOAQUIN, OCAL HEALTH DISTRICT <br /> FF CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 N1AY 2 4 ?978 <br /> 7 - - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires- l Year From Date Issued <br /> M Complete .In Triplicate <br /> Application is hereby made to the San Joaquin. Local Health .District fora permit to construct <br /> 4 and/br, 'install the work herein described.- This,...application is made in compliance with San <br /> 1 Joaquil County Ordinance No. 1862 and the Rules and. Regulations sof the San Joaquin Local. Health <br /> District. �t�Ztvi ; <br /> EXACT °STREET ADDRESS' W ; ,�� _: CITY/TOWN <br /> Owner's Name Phone <br /> Addr°essCi ty <br /> Contractor's Named' l License# 7 Phone -* C <br /> rt�_NWTOM11INSURANCE OddIS CERTIFICATE OF WORKMAN'SFILE WITH SJLHD? YES _- <br /> F TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION Q DESTRUCTION F1 <br /> WELL CHLORINATION Q WELL- ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT Cal <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 0 PIT PRIVY <br /> k 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 /> k Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled , Dia. of Well Casing <br /> w-90mestic/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 Instal ed b : <br /> PUMP INSTALLATION: Contractor <br /> { Type of .Pump H.P. <br /> 3 <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP ( State Work Done Z <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce3ure <br /> I hereby certify that I have prepared this -application and that the work will be done in accordant <br /> I 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 JJNSPECTPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SiGNE ITLE: DATE: S' <br /> DR W PLOT *PNoN REVERSE SIDE <br /> FOR DEPARTMENT' USE ONLY <br /> PHASE I O <br /> APPLICATION ACCEPTED BY / � ___ DATE`„ ? <br /> ADDITIONAL COMMENTS : <br /> PHASE ..II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> " INSPECTION BY DATE INSPECTION BY - DATE ,0 <br /> Fw Ia9r •l 78 <br /> _Rut► 17_77 � �" <br />