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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. a, <br /> Tel (209) 46676781 <br /> Date Issued 8'=8=78 <br /> APPLICATION FOR WELL CNST —[TION OR PUMP PERMIT <br /> This Permit Expires 17'Year From Date Issued . <br /> Complete In Triplicate <br /> 'Application is hereby made to the San Joa uin <br /> q 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 /> EXACT STREET ADDRESS CITY/TOWN <br /> ,4Z <br />, . Owner's Name Phone <br /> Address LSEA <br /> City <br /> Contractor' s Name License Phone E:�l—.2 'lQ._ <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATI01"! IPJSURAtlCE ON FILE WITH SJLHD? YES NO <br /> TYPEOFWORK (Check}T NEW WE .0 DEEPEN ❑ ry RECONDITION'❑ DESTRUCTION F) b <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST:---SEPTIC TANSEWER LINES5,-21.fPIT PRIVY --� <br /> SEWAGE DISPP SAL, r CESSPOOL/SEEPAGE PIT — OTHER ~. <br /> PROPERTY ,LINFAD-. RIVATE DOM STIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE STYPE OF WELLCONSTRUCTION SPECIFICATIONS ; <br /> Industrial _.ixY Cable Tool Dia. of Well Excavation f <br /> Domestic/private Drilled' Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing— �,<�_ <br /> Irrigation Gravel Pack ?'.De,pth of Grout Seal <br /> Cathodic Protection _Rotary Type of Grout <br /> a <br /> Disposal Other T Other. Information <br /> Geophysical Surface Seal Insta e b : <br /> PUMP, INSTALLATION: . Contractor <br /> Type of Pump H.P. <br /> i ! <br /> PUMP%REPLACEMENT: [1 State Work Done <br /> PUMP REPAIR: + _ ❑State Work Done <br /> DESTRUCTION OF WELL: Wel l -Diameter �«A roximate Depth <br /> P P' P <br /> Describe Mate—r—ial and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordancf <br /> with San Joaquin County Ordinances., State Laws , and .Rules and Regulations of the San Joaquin Local ` <br /> Health District. ` H-ome'-owner- or licensed agent' s signa'toreO 'tortifies 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,Fin such 'manner as to become subject to Workman 's Compensation <br /> Taws' of 'C'al'ifornia. ""-­ <br /> I WILL CA FOR A UT SP PRIOR-.TOGROUTING AND A FINAL INSPECTION. <br /> SIGNE <br /> TITLE: c DATE: <br /> DRAW PLOT PL N ON REVE S SIDE <br /> PHASE I <br /> F R DEPARTMENT USE ONLY <br />. � � <br /> APPLICATION ACCEPTED BY DATE Z W 7$` <br /> ADDITIONAL COMMENTS: <br /> PHASE A.4 I GROV T INSPECTION PHASE III INAL INSPECTION / <br /> INSPECTION BY _ DA-TE —�� INSPECTION BY 6✓ ,DATE Z <br />[' n L 7 7( 1 <br />.LH 1426 �M:w- .- 19-77 <br />