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u <br /> FFICE USE: SAN JOAQUIN LOCAL HEALTH .DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205:; [Date <br /> mit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued -/D -7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District foraermit 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. 4 <br /> EXACT STREET ADDRESS oq4Z <br /> A rofCITY/TOWN E <br /> Owner's Name <br /> S .S.` <br /> Address Phone-U-2 <br /> City - . <br /> , Contractor s Name License#, ; "Phone <br /> _ w ! <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION IN,; R C ON FILE WITH SJLHD'?� YES t—R7 0 k <br /> TYPE 2.F-WORK-(Check,) : NEW"WELL .DEEPEN ❑ -REONDiTIONwO DESTIRUCTION[] ' <br /> WELL. CHLORINATION <br /> 0 WELL ABANDONMENT p OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR @9;- PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TAN .� SEWER LINES PIT PRIVY <br /> SEWAGE DIS SAL ICED CESSPOOL/SEEPAGE PI OTHER <br /> PROPERTY LIN PRIVATE D MESTIC WELL PUBOC D MESTIC WE <br /> INTENDED USE'. TYPE OF-WELL. CONSTRUCTION SPECIFICA <br /> Industrials -Cable Tool Dia. of Well Excavation TIONS <br /> --___,Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> -L, Cathodic Protection Rotary <br /> Disposal 1 Type of Grout s <br />__,�eophysical Other Other Information <br /> Surface Seal InstA111ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Al _.1 I �4.... <br /> PUMP REPLACEMENT: <br /> # H.P <br /> Q State Work. Done <br /> PUMP REPAIR: [istate Work Donegroxee. <br /> DESTRUCTION OF WELL: -Well Diameter t <br /> Describe Material and Procedure APProximae Depth ,. <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 .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 /> C WILL CALL FORA GROUT I SPECTION PRIOR TO GROUTINGAANDIINAL INSPECTION. <br /> iIGNED TITLUKAW DATE: l'N ON RIDE , ; -. <br /> ----- <br />'.HASE I Z ZMIEP, RTMEN USE ONLY ;� �. <br /> SPP- LIGATION ACCEPTED BY <br /> DDITIONAL COMMENTS: 0 DATE (0 t Z9 <br /> PHASE II GROUT IN <br /> VSPECTION BY DATE INSPECTIPHASE III FINAL INSPECTION <br /> DATE <br />-► 14 26 Rev. 9/78,_ ON BY, � � � . -Zp-� <br />