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%N JOAQUIN LOCAL.. HEALTH DISTRICT <br /> FF CE USE: 601 E:»Hazelton Ave. , Stockton, CA 95205 remit No. -7q-;5b 9 <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI Date Issued_ <br /> (,Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health Di rict fo* 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 <br /> 'EXACT STREET ADDRESS CITY/TOWN L..- <br /> Owner's N'amelblupa Pat Laz Phone s <br /> Address. �►W i City n�x:' Q,QS/9i <br /> Contractor's Name ' GC c License# Phone o <br /> TS CERTIFICATE OF WORKMAN-_S-COMPENSATION � NSURAINCE ON FILE WITH-SJLHD? YES <br /> TYP£-;�'OF�ORK=(-Che-ck-).`"NEe EL.L DEEPEN❑ RECONDITION.❑ DESTRUCTION d <br /> ^ WELL CHLORINATION E] WELL ABANDONMENT Q OTHER O <br /> PUMP INSTALLATION [ PUMP REPAIR{] RUMP REPLACEMENT L1 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE 0o f" PIT PRIVY -� <br /> . SEWAGE DISP�IELD S(00 -7E <br /> OTHER <br /> o PROPERTY LINE - PRIVA�ESTIC WELL__ PUBLIC WESTIC W�LE <br /> INTENDED USE' TYP OF.WELL. CONSTRUCTION SPECIFICATIONS <br /> In ustriaT__ able 7001 Dia. of We Excavation <br /> =Domestic/private Drilled Dia. of Well Casing <br /> omestic/public Driven Gauge of Casing <br /> �_ ... Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout � <br /> Disposal Other Other Information <br /> ��Geophysical Surface Seal Ins <br /> ta e <br /> UMP INSTALLATION: Contractor <br /> Type of Pump L <br /> PUMP' REPLACEMENT: . ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done r <br /> DESTRUCTION ryOF WELL: Well Diameter :Ap�raxmate=Depth -..� <br /> Oescribe Mater a an Proce ure <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 /> .hot employ any person in such manner as to became subject to Workman's Compensation <br /> laws of California'." <br /> 1-WILL CALL. FOR A GROUT INSPECTION PRIOR TO GROUTING AND A,%FINAL INSPECTION. <br /> SIGNED TITLE: r DATE: 5//S <br /> ` ON REVERSE-SIDE) , <br /> FOR <br /> DEPARTMENT US <br /> ` PHASE I- <br /> U TION ACCEPTED BY Qij DATE <br /> /*3 //-,) g <br /> ADDITIONAL COMMENTS: <br /> PHASE -11 GR UT INS ECTI N PHASE III 'FINAL'INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 'EH' 14 26 Rev. 9/78• <br /> - <br /> I <br />