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SAN JOAQUIN..„LOCAL HtAL1H UISIRICI <br /> FFICE USE: 1601 E. Hazelton;Ave. , Stockton, CA 95205 Permit No. '7 '?_7 c / <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -717-7 7 <br /> This Permit Ex .ices- 1 ' Year From Date Issued <br /> (,Complete In Triplicate) o <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. T.his<application is made in compliance with San . <br /> Joaquin- County Ordinance No. 1862. and the Rules and Real ati ons .of the San Joa.qu.i.n Local Health � <br /> District. <br /> EXACT STREET ADDRESSf r] CITY/TOWN <br /> - 4 <br /> Owner's Name Phone = <br /> Address �5� � c.g= 1 = City. <br /> -- <br /> Contractor's Mame 4 � ,ir License Phoned =,��-/ <br /> IS CERTIFICATE OF WORKHAN'S COMPENSATIO'2 INSURANCE ON FILE WITH SEW YES NO <br /> 71.rte. . --�' <br /> TYPE OF WORK-(_C,heck.): .--NEW--WEL=L B--�--DE-EPE�N-8--�-�`"RECOND'ITION'Q-”—D-E RUCTIONr-_...�.,�._. .-�- <br /> d <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER O� ; <br /> PUMP INSTALLATION Eg PUMP REPAIR❑ PUMP REPLACEMENT [] r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE IT 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 /> XDomesti 6/private Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casing i <br /> I rri g t—fon Gravel Pack Depth of Grout Seal _ I Ck <br /> Cath ') Protection Rotary Type of Grout _ (b- <br /> Dis oral` Other Other Information t t <br /> Geophysical al c Surface Sealllnstal ed_Iby: <br /> PUMP INS3'ALLATI:ON: Contractor � <br /> Type of Pump 1,H­P' <br /> PUMP RE-PLACEMENT: []State Work Done__ g _ <br /> PUMP REPAIR: *., ❑State Work Done °"' <br /> DESTRUCTION OF WELL:%-,, ell Diameter Approxima e Depth a <br /> Descrtbe._Material and Procedure I Y <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. " 4 <br /> I- WILL CALL GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: _ DATE: 1��_7 2 <br /> DR W PLOT PEA ON REVERSE SIDE <br /> FOR DEP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BDAT£/:?JAZ ho -) <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ` <br /> INSPECTION BY DATE INSPECTION BY C , ATE q &h�,) <br /> EH 1426 Rev. 12-77 - "1/78 2M <br />