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p Ir <br /> Ce>4x l6 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FIDE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ' <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued -5L7 <br /> j This Permit .Ex ire s. 1 Year From -Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> kand/or in 'the work herein described. This application is made in compliance with San <br /> Joaquin County' Ordinance No'.AlM 2 and the Rules and Regulations of the San' Joaquin Local Health <br /> District. <br /> ' EXACT STREET ADDRESS Sow Z'i{�w a�7� +�a� CITY/TOWN <br /> Owner's Name Phone <br /> Address .. fs-�` rl� City <br /> Contractor' s Name License# r ti37�-s""' one 6 <br /> IS CERTIFICATE OF WORKIiAN'S COit S TIO] lI,3SURANC'E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL 'CHLORINATION 0 WELL ABANDONMENT © OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR(21 PUMP REPLACEMENT 0 <br /> C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> Domestic/privat6"` Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> } _ cLIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ tri <br /> Disposal { Other Other Information <br /> - Geophysical . Surface'Sea1 Installed by: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: State Work Done eA Lft.)b -- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Procedure <br /> I hereby certify that I have prepared this application and ,that the work will be done in accordant <br /> with San Joaqui-n County Ordinances , State Laws, and Rules and. Regulations of the San Joaquin Loca' <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 /> I WILL CALL FOR A GROUT INSPECTION PRI R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - 4 DATE. <br /> N ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 8Y DATE r <br /> , ADDITIONAL COMMENTS : <br /> PHASE. II GROUT INSPECTION PHASE� III FINAL INSPECTION <br /> ( INSPECTION BY. DATE INSPECTION BY. DATE.T <br /> —1 /78 _ M <br />