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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: -1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.�!Z'S,3 <br /> Telephone: J209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issue _7 <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 ADDRESS / Q t m;v �Cc� CITY/TOWN .4,04 <br /> Owner's Name /" s. %ekIe eycl.'s ` r e tca,!9LPhone 79 7 .63.2 Y�f' <br /> Address 1:776 6 N, A3,v w-S Ci ty__ o c0 <br /> Contractor's Name LK 4 ,v t c -/ L-L ;y;A/d-i cense#_?A?J 23 Phone <br /> _ 34 g 16 7 g <br /> _IS CERTIFICATE OF WORKMAN'S COMIPENSATIOM INSURANCE ON FILE WITH SJLHD? YES 0�^ <br /> TYPE OF WORK (Check) : NEW WELL,K DEEPEN ❑ RECONDITION DESTRUCTION c <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER ( <br /> PUMP INSTALLATION K PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> 'DISTANCE TO NEAREST: SEPTIC TAN C L' SEWER LINES/D.0' PIT PRIVY lv aou e <br /> SEWAGE DISPOSAL FIELD"A/r CESSP OL/S EPAGE PIT jus OTHER XZ1.r� <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 /,,,2 <br /> ' <br /> Domestic/private Drilled Dia, of Well Casing *1ri <br /> Domestic/public Driven Gauge of Casing a . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Na ar A/ T <br /> Disposal —�'-�• <br /> Other.- Other Informat7an <br /> Geophysical Surface Seal Installed b : c ,�, <br /> PUMP INSTALLATION: Contractor �Gt,IAAF <br /> Type of Pump � H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> LUMP REPAIR: (]State Work Done <br /> ESTRUCTION OF WELL.: Well Diameter <br /> - 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 e-inploy 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 /> SIGNED � <br /> TITLE: Lo-- DATE: )-717 <br /> D P N ON REVERSE SIDE <br /> PHASE I FOR DEPTRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; �/Z_/ 2f <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 "� : 9/78 2M <br />