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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFIC£ USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Tele hone:5209 466-6781 <br /> { }` 4+ ) Date Issuedr- <br /> ` __)G1 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> n 11 � t .. <br /> be <br /> t� � t (Complete In Triplicate) j <br /> wt <br /> Dom[ 03�- c5 <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 Nd.' 1862 and the Rules and' Regulations of the San Joaquin -Local Health <br /> District. <br /> i . EXACT STREET ADDRESS �,�,, CITY/TOWN <br /> Owner's •Name Phone EU--6�/ _- <br /> Address "� . _City =criv <br /> Contractor's Name (License#172 Phone <br /> IS CERTIFICATE OF$1'0TZK_AAN'S COMPENSATION INSURANCE ON FILE WITH.=SJLHD? YESI 0' <br /> � • TYPE OF - _e • .. ... - - <br /> WORK (Check) NEW 'WELT1:0 -6EE.PSEf- ❑ RECONDITION ®� DESTRUCTION( Z oe <br /> WELL CHLOR�I�fATION Q WELL ABANDONMENT 50 OTHER FA <br /> PUMft INSTALLAT�LON ❑ PUMP REPAIR 0- PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC �TANK SEWER LINES PIT PRIVY <br /> SEWAGE �DISPOSAL FIELD CESSPU4L/SEEPAGE .PIT OTHER � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEA- �1 <br /> ; . . .:- INTENDED USE TYPE OF_WELL_ CONSTRUCTION SPECIFICATIONS j <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestid/private 3 Drilled Dia. of Well Casing_ <br /> Domestic/public `'` i Driven Gauge of Casing yr <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection,, Rotary Type of Grout <br /> Disposal t Other Other Information €� <br /> Geophysical Surface Seal Installed -W.' <br /> nsta ed _-y: . <br /> I PUMP INSTALLATION: Contractor - <br /> r Type `of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done - {L <br /> 4PUMP - - - <br /> ❑State'Work' Done <br /> ` DESTRUCTJON OF-WELL: Welly Diameter �6u Approximate Depth mss' f�&K ' - <br /> Descri be ;Maters a and Proce ure <br /> I hereby cerci fy that' I have prepa,r6d ,th.if,-application and that -the work will be done- 'in accorda <br /> With San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San.•Joaquin_:Loc <br /> Health -District. Home owner •or license�tl 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 /> frk emplo any person in such manner as to become subject to Workman's Compensation <br /> I%WN of C ifornia. " t <br /> I WI°LLC L 'F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL- INSPECTION. <br /> SIGNED $ TITLE: - DATE: <br /> (DRAW PLT PLN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION _ �. w3_, PHAS III -FINAL INSPECTION <br /> INSPECTION 'BY DATE Tc t .' � INSPECTION BY DATE <br /> EH 14 26 Rev. 9 $ - ....► .9/78 2M <br />