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} - ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE- 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -73 <br /> Telephone. (209) 466-678I _ <br /> rl <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Date Issued S / 7 <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate a <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 /> ,oaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s Name Phone ��1 �.�� / <br /> Address City <br /> Contractor's Name /I n s e# 3�1y Phone gVl-.ZSr16 <br /> IS CERTIFICATE OF WO � O �P 1 I TA*al! FILE WITH SJLHD? YES NO <br /> TYPE. OF-WORK- (Check) :- .NEW..-WELL DEEPEN ❑ RECONDITION ❑ - - <br /> DESTRUCTION{]-WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANI SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL, FIELD /± CESSPOOL/SEEPAGE PIT OTHER �. <br /> PROPERTY Lim?a4PRivATE ESTIC WELL -----PUBLIC DOMESTIC WELL --- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS- <br /> Industrial _Catil-e--Tool---Dia.- of Well Excavation <br /> _*—Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing el <br /> Irrigation XGravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout e <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: r-1.c�1En <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done - E, <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <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 far -whi ch_thl s_.-.permi.t i.s i s.sued, 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 G UT IN2EWIONTeOR TO GROUTING AND A FINAL INSPECTION. <br /> i <br /> SIGNED TITLE: DATE: <br /> D W PLOT PL N ON REVE S SIDE <br /> FDR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_141 "INAL INSPECTION <br /> INSPECTION BY A DATE . INSPECTION BY DATE ' <br /> ELL-1 4 2 6' Rev. 12-77 ___ 1 /78 2M r <br />