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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P�F_FICEUSE: 191601 E. -Hazel'ton Ave. , Stockton, CA 95205 Permit No. S <br /> Telephone: (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7- <br /> u <br /> (Eomplete .'Ih'Triplicate) <br /> Application is hereby made to the San Joaquin Local Hea.lth, District for' a.rpermit 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 /> EXACT STREET ADDRESS c CITY/TOWN <br /> Owner's Name_'- 't� _ .__._ -- IPhone <br /> Address <br /> � � Ci ty <br /> Contra <br /> ctor s .Name License Phone 37 <br /> IS CERTIFICATE._OF WORKMAN.'S COMIPENSATION INSURANCE- ON FILE WITH SJLHD? -YES O <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION rl DESTRUCTION <br /> WELL CHLORINATION Q - .WELL ABANDONMENT d OTHER 0 e <br /> PUMP INSTALLATION 0 PUMP REPAIRL& PUMP REPLACEMENT <br /> PDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY x <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY EINE =. PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELT <br /> INTENDED USE.. TYPE OF .WELL._� CONSTRUCTION' SPEC.IFICATIONS <br /> Industrial Cable Tool Dia, of We Excavation <br /> �omestib/public <br /> omestic/private Drilled , Dia. of Well Casing Driven Gauge of Casing <br /> Irrigation _ E Gravel; Pack Depth of Grout Sea <br /> _r_____ <br /> Cathodic Protection jRotary Type of Grout <br /> __;_Disposal Other . Other Information ' <br /> Geophysical � � � Surface Sear Insta ed -� <br /> sw � <br /> PUMP INSTALLATION: Contractor. .. <br /> Type of Pump H.P. <br /> RUMVREPLACEMEHT: i � ]State, Work. Done <br /> -- - - r-- <br /> PUMP REPAIR: State Work Done _ 02 e-rS l{ <br /> DESTRUCTIONJOF WELL: Well Diameter , �r . <br /> Describe Materia and Procedure <br /> Approximate Depth <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 Distract: 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 FORA r_DNIT I <br /> SIGNED SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE: �✓ DATE: r� Pk.4'ZJ <br /> ` R W P PL-VN ON REVERSE DE <br /> PHASE I I.R EP TMEN ONLY <br /> TP-PLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 7. <br /> PHASE II GROUT INSPECTION ,-� -PHASE II Fi-NAL INSPE TION <br /> /V C17 <br /> INSPECTION 8Y�' .i -DATE r ��,INSPECTION BY DAT <br /> EH 14 26 Rev. 9/78 � <br /> ajr 0M <br /> M <br />