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AN JOAQUIN LOCAL. HEALTH DISTRICT <br /> EOR-OFFI�CE USE: 601 E: Hazelton Ave. , Stockton, CA 95205 emit No. -7q-S6 9 <br /> Telephone: (209) 466-67'81 .. , <br /> APPLICATION FOR WELL CONSTRUCTION OR UMP PERMIT' Date Issued �! <br /> �as}!o!1 - I�, 7pa/4�JJ►+ � t <br /> (Eaiiip l ete In Tri pl i cateG, �, � . <br /> Application is hereby made to the San Joaquin Local Health Di riot fora 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. .K <br /> EXACT STREET ADDRESS v 1 oo Wow � CITY/TOWN �o !�s�? yo; <br /> Owner's Name 914 a k Iv Phone <br /> Address aw <br /> - ... Ci"ty Ln��.fa t/u3 <br /> Contractor's Name C c License# Phone 6 o <br /> _. _ .. <br /> IS CERTIFICATE OF WORKMAN'S-COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES UO <br /> TYPE�4F-WORK--(Che-ck'):---- EleWELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ - <br /> WELL CHLORINATION C3 WELL ABANDONMENT ® OTHER f_-3 <br /> PUMP INSTALLATION ❑ PUMP REPAIR C7. PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK a! SEWER LINE Oo PIT PRIVY \ <br /> SEWAGE DISP SAFL IELD �p�ifESSP�4L/SEEPAGE PIS— OTHER <br /> o PROPERTY LINE - PRIVATE DOMESTIC WELL...,/ PUBLIC D MESTIC WELL <br /> INTENDED USE' TYP OF-WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> =FfDDomestic/public Driven Gauge of Casingka <br /> Irrigation Gravel Pack Depth of Grout Seal �'I <br /> Cathodic Protection Rotary Type of Grout ho,- 'VR&4 C <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> SUMP 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 rDepth_ <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 /> ".1 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 nia.11 <br /> I_ WI:LL' CALL FOR A GROUT INSPECTI N PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE: )ATE: s /S <br /> (DRAW PLOT PL ON REVERSE SIDE • <br /> R DEP RTMENT USE ONLY <br /> PHASE I- µ <br /> PP�{�TION ACCEPTED BY DATE 3 //—,) 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III ' FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH l4 26 Rev. 9/78• 0/7Q 9M <br />