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r SAN JOAQUIN LOCAL HEALTH UIS�IRICI <br /> E FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 9 &fes <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued_7_ X_,7g-� <br /> This Permit Expires l Year From Date Issued <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 /> `oaquin County Ordinance No. 1862 and the Rules and Regulations .of the San Joaquin Local Health <br /> C4strict. �3��� S'�i►l�'�U� <br /> EXACT STREET ADDRESS 5'--i 1,, CITY/ti� A4 <br /> Owner's Name C D C K9 Phone <br /> Address ?. Ci ty LSC:AZoA/ <br /> Contractor' s Name f _ air, License#a79.v/ea Phone ,V5- v7 <br /> _TS CERTT F"T CATS OF WORKI IAN'S. CTMPENSATION IIISURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER n— 030111 <br /> PUMP INSTALLATION ❑ PUMP REPAIRiZJ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED <br /> ELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: COState Work Done_j?f.AAc t,e Sj haw j?ppQj;z ./��,�,sia. 4- <br /> DESTRUCTION OF WELL: Well Diameter Appro�mx ate Depth <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 WILL CALL FRA GROUT I PECTION PRIOR TO GROUTING AND A FIN4 INSPECTION. <br /> SIGNED TITLE: TE: 7 <br /> (DRAW PLOT PL N ON REVERSE SI E <br /> FOR DEPARTMENT USE ON �- <br /> PHASE I <br /> APPLICATION ACCEPTED BY G DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONHASE III INAL INSPECTION <br /> INSPECTION BY DATE V I CTION BY 64 : DATE "8 <br /> EH 1426 R - ] __ 1 /78 2M <br />