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SAN JOAQUIN LOCAL HEALTH DISTRICT �- <br /> �` CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No,,17'Jc-- <br /> Telephone: (209) 466-6781 Date Issued L// 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> C( 2-c4a-3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons ruct <br /> and/car install the work herein described. This 'application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> nistrict. .42 } <br /> EXACT STREET ADDRESS lc7.t. �t -y , h ,4 - CITY/TOWN__ <br /> Owner's Name Phone <br /> Address c f�_! Ci ty , � _)Contractor' s Name - ,,, w� � License# Phone .. ; <br /> IS CERTIFICATE OF WORKMAN'S COmPENSATIO`1 INSURANCE ON FILE WITH SJLHD? YES 1140 <br /> TYPE OF WORK (Check) : NEW WELL L ' DEEPEN ❑ RECONDITION C) DESTRUCTIONd <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE TO NEAREST: SEPTIC TANK__ZLA; a SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATEDOMESTIC WELL PUBLIC DOMESTIC WELL d�4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation__ --4r 1111 <br /> Domestic/private Drilled Dia. of Well Casing r. <br /> Domestic/publi Driven Gauge of Casing <br /> -_ Irrigation apt, i'/� �P _Gravel Pack Depth of Grout Seal <br /> Cathodic Prot ction _Rotary Type of Grout �rAA <br /> Disposal _Other ,, Other Infarmatioh <br /> Geophysical Surface Seal Installed" <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 CAL4 FOR ,A GROU INSPECTION PR TO GROUTING AND A FkNAL INSPECTION. <br /> SIGNED { '�,: l TITLE: DATE: / <br /> (DRAW PL N ON REVERSE -SIDE) <br /> FOR DBPARTMENT USE ONLY <br /> PHASE I <br /> FP—PLICATION ACCEPTED BY . . - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426-----Re-y- 12-77 1/78 2M <br />