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0 • <br /> Ca!!14 4- 0 � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS FFICE US1E 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No- <br /> Telephone: (209.) 466-6781 <br /> r APPLItCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _&_2r <br /> Thlis Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate) <br /> Application is hereby made tol 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 Na. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. p0 w -I.GlStct�GM. 7� // <br /> EXACT STREET ADDRESS oM+K 4rZi d- W CITY/TOWN c1;4v;.Z1wA, <br /> Owner's Name Phone $ <br /> Address le! City X,4 <br /> .f- <br /> Contractor' s Name a. . License# 1937"--Phone 416y —767-` <br /> IS CERTIFICATE OF WORKMAN'S COMP ATION INSURANCE ON FILE WITH SJLHD? YES k NO <br /> TYPE OF WORK (Check) : NEW WELL❑ . DEEPEN ❑ RECONDITION ❑ DESTRUCTION E] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIRP PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEjDISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS x <br /> IC Industrial le Tool Dia. of Well Excavation - d, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump T r' — xlel/ >rP. d <br /> PUMP REPLACEMENT ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> - LOIdALg) <br /> DESTRUCTION OF WELL: Well Diameter Approximate Irepth <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." <br /> 1 WILL CALL FOR A GROUT INSPECTION-PR WR-10 GRO TING AND A FINAL INSPECTION. . <br /> SIGNED „ LE: r DATE: / <br /> OPW PLOT ON REVERS SIDE <br /> FOR DEPARTMENTUSE ONLY <br /> PHASE I t �J <br /> AMPACCEPTED BY ltrcY d yl'1< � DATE <br /> ADDITIONAL COMMENTS: �I <br /> PHASE II GROUT INSPECTION f PHASE III FINAL INSPECTION <br /> ; INSPECTION BY DATE INSPECTION BY 1 DATE 1°ol <br /> EH 1426 Rev.-T2=77 - 4 1/78 2M <br />