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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 9-,3?� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued4- -7 9 <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. <br /> EXACT STREET ADDR S / �'�/ . CITY/TOWN <br /> Owner's Name Phone 36, /.�'7 0 _ <br /> Address 11yrn City <br /> Contractor's Name LicenseY�a13 7 3 Phone z6 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"!CE ON FILE WITH SJLHD? YES -✓ _ 1�0 <br /> TYPE OF WORK (Check) : 4NEW WELL,Q ..i DEEPEN 0, RECONDITION DESTRUCTION <br /> _ �-----WELL-- CHLORINATi1ON--Q'---.-WELL ABANDONMENT IO OTHER Ai <br /> PUMP INSTALLATION Q PUMP REPAIR.❑ PUMP REPLACEMENT.. I� <br /> DISTANCE- TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPFOL/SEEPAGE PIT OTHER N <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DO ESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 0 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private a j Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation - Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Roftary Type of Grout = <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 'I H.P. <br /> PUMP REPLACEMENT: _ F;�State Work Donep <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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.". _ fV <br /> I WILL CAU-IFOR A GROUT INSPECTION IOR- TO GROUTING ALD A FINAL INSPECTION. <br /> SIGNED . TITLE: DATE-.-_4--.73 <br /> P ON REVERSE E _V. <br /> FOR D P RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z-t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - Z—° ?� <br />,FH Id 9A Rate_ 4/7R "4/7R 9M <br />