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/ SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> FOR OFFICE USE: 4/ 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permit No. i 9-1d <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate) -2 1 <br /> Application is herebymade to the San Joaquin Local Health District for a it to obstruct <br /> q p <br /> and/or install the work herein described. This application is made in compliance with San <br /> k.'oaquin County Ordinance No. 1862 and he Rules and Regulations of the San Joaquin Local Health <br /> District. s' <br /> EXACT STREET ADDRESS - ��/� p ( �- n - s � ITY/TOWN <br /> Owner' s Name LaL,8 te Phone <br /> Address . 9 City <br /> Contractor's Name Li cense# < Phone <br /> IS CERTIFICATE OF WORKMAN S COMPENSATIO"1 I111ISURA.110E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ 72 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER F-1 a <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [� w <br /> DISTANCE TO NEAREST: SEPTIC TANK /00' SEWER LINES PIT PRIVY D� <br /> SEWAGE DISPOSAL FIELDS 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 Well Excavation <br /> C Domestic/private Drilled Dia. of Well Casing 111" R <br /> Domestic/public Driven - Gauge of Casing A0,v,a/I <br /> Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection __X_Rotary Type of Grout <br /> Disposal Other Other Information _ fj <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR• ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEb TITLE : DATE: /al-7g <br /> DR W PLT L N ON REVERSE SIDE <br /> FOR EP RTMENT USE ONLY <br /> PHASE I /Z—Z2 7� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION a PHASE III 5INAL INSPECTION <br /> INSPECTION BY DATE 1112 '? ! INSPECTION BY ATE-2,—2 7 <br /> V1 <br />.EH 1426 Rpv_ 12-77 1 /7 R" 9M <br />