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I/ SAN JOAQUIN LOCAL. .HEALTH DISTRICT <br /> FOS FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ;!g_1�4Sq <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> 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 /> 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. <br /> EXACT STREET ADDRESS Q a T 4 R:b ur 14- CITY/TOWNfeEA&dId <br /> Owner's Name { Phone <br /> Address Tp . . 0 Ci ty_ <br /> PhoneContractor's Name aL C AUL P cense# Cp Zj <br /> IS CERTIFICATE OF WORKMAN'S. COMPENSATIO"JJNSURAINCE ON FILE WIT SJLHD? YES NO $ <br /> TYPE OF WORK {Check} : NEW WELL EEPEN 0 RECONDITION Q DESTRUCTION[D <br /> WELL CHLORINATION C1 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIRIC] PUMP REPLACEMENT CI <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL _FIELD,? j CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE `-- PRIVATE-DOMESTIC ;W£'LL PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYP SWELL CONSTRUCTION SPECIFICATIONS <br /> -Indus-tri-al­ Cabl a Tool Dia. of Well Excavation 12' <br /> Da is/private Drilled Dia. , of Well Casing <br /> omestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack ' ,; D.epth,of-Gr_o.ut-Sea_.- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical y ~�-Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor i <br /> Type, of Pump _ F H.P. <br /> PUMP' REPLACEMENT: Q State_)Work Done '� ' ' 3 <br /> PUMP REPAIR: ❑State Work Done <br /> ' DESTRUCTION OF WELL: WelliDiameter. Approximate Depth . <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this applicati-fln_and..that_the work wil�._be .done in accordani <br /> with San Joaquin County Ordinances , State Laws , and pules and Regulations of the San �Joaquin Loca' <br /> Health District. Home owner or licensed agent's signatur -deirti,fies the following: <br /> "I certify that in the performance of the work° for which th `5• -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.."" 1_ L <br /> I WILL- CALL FOR A ;G-_01T� I' S-PECTION PRIOR TO GROUTING AND A FINAL,INSPECTION. <br /> SIGNED TITLE: � DATE: () J3 Av <br /> (DRAW P OT PLAN ON REVERSE SIDE . <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B ; .' DATE ev _e 3 _7. <br /> ADDITIONAL COMMENTS: <br /> ► PHASE II GROUT INSPECTION ' ►, -- -5 PHASE III FINAL INSPECTION <br /> INSPECTION' BY DATE ,. .INSPECTION BY DATE�r-�� <br /> r <br /> Fu Ia9F an„ 17_77. ,. 1/78 2M <br />