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f 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL C�ONSTRIJ�TION OR PUMP PERMIT Date Issued .3 .3 <br /> - -7 <br /> . 44A "43 <br /> (Complete In Triplicate) <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. 95tyfv2/ At 6_— A� , —, <br /> EXACT STREET ADDRESSA r-%2-A094f CITY/TOWN <br /> Owner's Name .7` _ _&:f der Phone -?-T / <br /> Address City e r?r <br /> Contractor's Name <br /> (L License Phone <br /> IS CERTIFICATE OF WORKMAN'S CO"kPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> ---- � NEW WELL WELL DEEPEN ❑ RECONDITCHLOR __��ION <br /> TYPE 'OF WORK (Ch. eck} : [� DESTRUCTION <br /> ( . <br /> ATION 0 WELL ABANDONMENT ❑ OTHER❑ j <br /> PUMP INSTALLATION, PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK/ee[5 SEWER LINE Sfd0,. PIT PRIVY <br /> SEWAGE DISPOSAL,FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN ® PRIVATE DOMESTIC WELL& - PUBLIC DOMESTIC WELL NIQ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WM Excavation <br /> ___,k�Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing Q , <br /> Irrigation Gravel Pack Depth :of Grout Sea -,r- <br /> Cathodic Protection Rotary Type of Grout o A-_f <br /> Disposal Other - ' r ;'• r` Other Information <br /> Geophysical Surface Seal Instal ed _b_y: D <br /> PUMP INSTALLATION: Contractor D��o ; � �� � CAE <br /> Type of Pum ,, � ,� <br /> PUMP REPLACEMENT: ❑State Work Done P. <br /> PUMP REPAIR: Q State Work Done <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 inaccordance <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 W.orkman's Compensation <br /> -laws of-..California. <br /> IM WILL CA FOR A GROUT-INSPECTION PR-IOR-TO -GROUTING. AND A FINAL INSPECTION. <br /> EIGED TITLE: s 'DATE: Y— /3— 7� <br /> L L ON REVERSE SI E TT"' <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE !DATE V 6 7 � <br /> EH 14 26 Rev. 9/78 �� -9/78 2M �' <br />