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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued "5- -2 <br /> (Complete In Triplicate) 2 o 6— <br /> Application <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. i{a:gS_f-f <br /> EXACT STREET AD//DRESS /S 2/Jn/. vc•T','J'' ee /?i/CITY/TOWN f�SGo% v <br /> Owner's Name Phone ;2 <br /> Address <br /> City /�i,vl., ,v <br /> Contractor's Name License#2.6576/ Phone 4 <br /> IS CERTIFICATE OF WORK'IAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? :YES -=n-NO 1�n <br /> TYPE OF WORK (Check) : NEW WELL q DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ L <br /> WELL CHLORINATION 0 WELL ABANDONMENT E3 OTHER 0 <br /> PUMP INSTALLATION [Qe — PUMP REPAIR 0 PUMP REPLACEMENT ❑ ,c, ; <br /> DISTANCE TO NEAREST: SEPTIC TANK �,f�,�e.SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE�IPRIVA7�FfESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public —Driven.- ; Gauge of Casing <br /> rrigation 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 /> PUMP INSTALLATION:' Contractowl/y.vr%1s�r1 <br /> Type of Pump L r H.P. <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP REPAIR: ❑State Work Donee-, <br /> DESTRUCTION OF WELL: Well Diameter i Approximate Depth <br /> `` -- Describe Material and Procedure <br /> WY <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-t-he'San Joaquin Local <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of theiwork for which this_per6it-is issued;-1 s ll <br /> not employ any person in such manner; as to become subject to Workman1s--Compensation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A..FdNAl SPECTION. <br /> SIGNED TI-TLE y DATE:4 <br /> - DR PL' L" N ON RE RSE SIDE <br /> iPHASE I A FO DEP RTMENT USE ONLY <br /> PEI ATION 'ACCEPTED-BY— Y,c� DATE S/?/-7-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE DATE / <br /> INSPECTION BY DATE S7 _ <br /> EM 14 26 Rev. 9/78 ! � 4/78 2M <br />