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sr T l <br /> F <br /> SAN JOAQUIN LOCAL EALTH--DISTRICT <br /> FFIGE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 mss- 4 <br /> " Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicae <br /> .. t ) fDCoO —! <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. .�862 and the. Rules and Regulations of the San Joaquin Local Health <br /> District. rZ,& ,(_VJ �sc-�.E_4_4a..t-U?' <br /> EXACT STREET ADDRESS., ��,2,yF� �I /�cl� - - CITY/TOWN <br /> Owner's Name At�1S c Phone <br /> Address City <br /> Contractor's Name & License#� /� Phone VY km <br /> IS CERTIFICATE -OF WORKMAN'S COOMPENSATIOM INS AmrF ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION 0 DESTRUCTION C31z <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 /-m-CA41J, ,a- ScRt�". <br /> v PUMP INSTALLATION CJ PUMP REPAIR❑ - PUMP REPLACEMENT ❑ U,1 <br /> DISTANCE TO NEAREST: SEPTIC TANK ice1..1- SEWER LINES PIT PRIVY a- IX <br /> — <br /> SEWAGE DISPOSAL FIELD/ao!: CESSPOOL/SEEPAGE PIT OTHER €� <br /> PROPERTY LINO'fPRIVATE DOMESTIC WELL{.. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We 1 _Excavation <br /> EEEDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _Gravel Pack Depth of Grout Sea <br /> Cathodic Protection __�X Rotary Type of Grout i <br /> t Disposal Other Other Information /,Ys I <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: r]State Work Done ' <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 IN ,ECT O PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: + <br /> . PL T N ON REVERSE. g_4 ZZ <br /> E <br /> JR DEPARTMENT USE ONLY . <br /> PHASE I . ;:;:� <br /> �- <br /> APPLICATION ACCEPTED BY DATE 3 -- 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJINAL INSPECTION 1 <br /> INSPECTION BY DATE _ INSPECTION DAT <br />=H 14 26 Rev. 9/78 - <br /> �6 <br />