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SAN JOAQUIN LOCAL HEALTH DISTRICT- <br /> FQRJFFICE USE: . 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7/---9� <br /> Telephone: (209) 466-6781 <br /> w <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3_,:-,)V, <br /> (,Complete In Triplicate) <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. 1862 and the Rules and- Regulations of the San Joaquin Local Health <br /> District, <br /> EXACTSTREET ADDRESS_,S D a E _ CITY/TOWN_ � <br /> Owner's Name ; (�� - aa <br /> Phone <br /> Address Q City <br /> Contractor's Name-044n. (2� SS J. License# Phone. % Vl :R <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAMU'ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [ DESTRUCTION t_i._ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION ,❑ PUMP REPAIR®---. PUMP REPLACEMENT E3W <br />` -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPO L/SEEPAGE Pte— OTHiR <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED. USE' TYPE OF,-WELL.. s CONSTRUCTION SPECIFICATIONS <br /> In ustrial 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 Sea <br /> Cathodic Protection Rotary _ Type of Grout <br /> Dis osal <br /> p Other Other Informat7on <br /> Geo h <br /> p ysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br />' PUMP REPAIR: ❑State Work Done <br />' DESTRUCTION OF WELL: Well 'Diameter <br /> ID Approxima e D pth QQ 4 <br /> Describe Mat ria and Prone ure 5 D <br />` I hereby certify that I have prepared this application and that the work will be done inccor an <br />' Vith 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 theperformance 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 .0 L FOR A OUT NSPECTION IOR TO GROUTING AND A FINAL-INSPECTION. <br /> SIGNE TITLE: DATE: QZZ2 . , <br /> JDRAW P T L N ON REVERSE SIDE - <br />.PHASE I --FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r, na.. <br /> DATE a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE ��`/INSPECTION BY-. DATE <br /> EH 14 26 Rev. 9/78 D( 3 i ah uelf -.U}- . <br /> - - . -_ _ I/// b I�-Ff rry ��fYJ I jYla� '4�t� ed. &4-1 4� a�,jl,yee 9/78 M <br />