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1/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —FORAFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 79- <br /> Telephoner <br /> 9!Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S'- <br /> (eomplete .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 /> EXACT STREET ADDRESS 4/-q o e 4Z-)----., CITY/TOWN <br /> Owner's Name L. <br /> Phone - 2 <br /> Address City t <br /> Contractor's Name license _-2hone 7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION DESTRUCTION[� , <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR e3-�- RUMP REPLACEMENT [3 <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- OTHER r' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTICEST s <br /> INTENDED USE TYPE OF.WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r <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 /> Disposal 7 Other Other Information ' <br /> Geophysical Surface Seal Insta ed <br /> E PUMP INSTALLATION: Contracto 7) A <br /> ` Type of Pump H.P. <br /> PUMP REPLACEMENT: mate Work Done !.1 !a s, �^ <br /> PUMPAEPAIR: QState Work Done <br /> "�� <br /> DESTRUCTION OF WELL:... Well Diameter� - <br /> f APprox�mate Dep h�` <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. 1ILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED c TITLE: DATE: "L-f <br /> D L T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> PPS LICATION ACCEPT€D BY DATE <br /> ,ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION PHASE III FINAL INSPECTION <br /> ;INSPECTION BY , DATE INSPECTION BY D E � 7 7 <br /> EH 14 26 Rev.' 9/78 _ 9/78 2M <br />