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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P5EF=FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 163S -631 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued (9-4-?y <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 � TI <br /> �CT1 . c ? o � <br /> EXSTREET ADDRESS ��� CI70WN LZA10.-I <br /> Owner's Name S!aPhone <br /> Address Ci ty^� �,� • _ <br /> Contractor's Name LicenseJ2,Z,,Zg2 Phonep7 <br /> TS CERTIFICATE,.OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES 0. <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 5d PUMP REPLACEMENT C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY U, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF "WELL.. ' ^{CONSTRUCTION SPECIFICATIONS <br /> Industrial `— Cable Tool Dia. of �kel Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea I� <br /> Cathodic Protectiont ,,Rotary Type of Grout <br /> Disko l - Other' Other Information <br /> Geophysical, Surface Seal Installed y: <br /> PUMP 'INSTALLATION: Contractor <br /> Type of Pump ~ H.P. <br /> PUMP REPLACEMENT: []State' Work Dg ae-­V..: <br /> PUMP .REPAIR: RState Work <br /> Doneaja <br /> DESTRUCTION OF WELL: WeT ] Diameter <br /> --._..-.Prp pxo xi.mad-e.JQep — <br /> --------DEscrtbe--Ma-te- '6 'an rP oceddre <br /> I hereby certify that I have prepared this application. and that the work will be done in accordant <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 WILL CAL FOR A G T SPECTION PRIOR TO GROUTING AND A FIN INSPECTION. <br /> SIGNED TITLE: DATE: �2�(DRAW PLOT PL N ON REVE SE SIDE , <br /> F R DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III JINAL, INSPECTION � <br /> INSPECTION BYDATE INSPECTION BY � DATE ,7?J';>7,,9 <br /> EH 14 26 Rev. 9/78 c�3 9/78 2M <br />