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- �N JOAQUIN LOCAL HEALTH DISTRI <br /> FFICE USE: 1601�'E. Hazelton Ave. , Stockton, CA 205 Permit No. , 3-3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (fomplete In Triplicate) <br /> -pplication 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 /> )aquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> _istrict. <br /> EXACT STREET ADDRESSj/ 3 J ��4,Af CITY/TOWN <br /> .vner's Name ��, crz t - /J Phone <br /> Address �OgA4r City C? r� j <br /> mtractor's Name LicenseS. 11�/ Phone Sly/% <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURA'NrF N FILE WITH SJLHD? YES X NO <br /> _fPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION DESTRUCTION[j <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION p PUMP REPAIR O PUMP REPLACEMENT ❑ <br /> M STANCE TO NEAREST: SEPTIC TANKS SEWER LJNES / PIT PRIVY <br /> SEWAGE DISPOSAL FIELDED . CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINV�4PRIVATE DOMESTIC WELLS PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of We 1 Excavation <br /> _Domestic/private Drilled Dia. of Well Casing ,, /{ <br /> Domestic/public Driven Gauge of Casing � ' d�j y , k <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed by: <br /> IMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 011MP REPLACEMENT: []State Work Done <br /> .1MP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordam <br /> 'th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> RBalth 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 /> I WILL C FOR GRO T I SP TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> GNED TITLE: Lk z DATE:; <br /> DR W PL T PL N ON REVERS IDE <br /> IASE I <br /> FOR DEPARTMENT USE ONLY <br /> "PLICATION ACCEPTED BY / f�c DATE 1977 <br /> 4DDITIONAL COMMENTS: ti <br /> PHASE IT GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> +*SPECTION BY n f/ _ DATE INSPECTION BY NM DATE � \ 1 -)- <br />