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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: x601 E. Hazelton Ave. , -'Stockton, CA 95205 Permit No. <br /> Telephone: (209), 466-6781 - -- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S- ,79 <br /> (Eomplete In Triplicate}. <br /> Application is_ hereby made to the San Joaquin' Local Health District- for a perEnit bD construct <br /> and/or install the work herein described. This applit-ition 'is made in compliance with San <br /> Joaquin County Ordinance No. 11862 and th ules and Regulations ,of the San. Joaquin Local Health <br /> District. Y.9/0 <br /> .EXACT STREET ADDRESS <br /> m, 4- ' 7c,povu,,t✓iITY/T0WN ... <br /> Owner's Name <br /> Address <br /> Phone <br /> e :Ci ty <br /> Contractor's- Name S ' <br /> License#t -7k.�h©ne- 76 ?'6 <br /> IS CERTIFICATE OF WORK�IAPJ'S COQ - <br /> -- FEN ATT <br /> ON FILE WITH SJLHD? YES - NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION DESTRUCTION� <br /> WELL CHLORINATION .# - WELL ABANDONMENT 0 - OTHER 0 a <br /> PUMP. INSTALLATION W PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. ... PIT PRIVY <br /> _ SEWAGEIDISPOSAL FIELD CESSP L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC pOT4jESTIC WELL <br /> 'INTENDED USE TYPE OF WELL <br /> d <br /> Industrial CONSTRUCTION SPECIFICATIONS,- <br /> Cable Tool Dia. of Wel Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> �___�Ir.rigation Gauge of Casing <br /> Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other <br /> Y. Geophysical Other Information <br /> Surface Seal Insta ed <br /> PUMP INSTALLATION: Contra ctor <br /> Typek of; Pump <br /> PUMP REPLACEMENT: H. <br /> Stat <br /> Q e Work Done - <br /> PUMPState Work Done ?� •° , " �. <br /> DESTRUCTION OF WELL: Well Diameter Y <br /> . . ._ <br /> Describe Materia anF-Procedure Approximate Depth <br /> I hereby .certify that I have prepared this application and that the work will be done in <br /> with San Joaquin County Ordinances , accordance: <br /> Health District.- Home owner or licensedeagent'sasiignatureacertifiestthesfollowof ingan Joaquin Local .1 <br /> "-I certify tanypn the performance of the work for which this permit is issued, I shall <br /> lawsnot employ any person in such manner as to become subject to Workman's Compensation <br /> of California. W ' <br /> L WILL .CALL FOR A GROUT INSP TI N TO GROUTING AND .A'..FINAL INSPECTION. <br /> iIGNE ITLE: ��- DATE:} �' } <br /> t D PLT L ON REVERSE SIDE i <br />'HASE I - I OR DEPARTMEN USE ONLY <br />,PPS ION ACCEPTED BY <br />,DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY PIiAS III FINAL INSPECTI N <br /> U_ DATE <br /> H 14 26 Rev. 9/78 INSPECTION BY DATE <br />