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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FnE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. � <br /> Telephane: (209) 466-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> 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 J,5g a4Va <br /> / CITY/TOWN. %9e-at.n,oa <br /> Owner's Name Pn► o roe �r`Ea� Phone.53V— <br /> Address'.. <br /> .5.3V--Address ;S-', .2 City o <br /> Contractor's Name r ' IL Ae/l A16 License#3 /Y/,23 Phone.34f /6-7 ; <br /> IS CERTIFICATE -OF WORKMAN'S CO",PENSATION INSURANCE ON FILE WITH SJLHD'? YES - 0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION [3 DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATIONX PUMP REPAIR 0 PUMP REPLACEMENT Q r, <br /> DISTANCE TO NEAREST: SEPTIC TANK 76'" SEWER LINES/ea"_ PIT PRIVY ate';- N t <br /> SEWAGE. DISPOSAL FIELD dlo�v'EESSPZL C /S EPAGE PIT ;V&.Jrr-OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL "K PUBLIC DOMESTIC WELD <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool _ Dia. of We 1 Excavation / <br /> •—Domestic/private Drilled Dia. of Well Casing s' <br /> Domestic/public Driven Gauge of Casing X <br /> Irrigation Gravel Pack Depth of Grout Sea - <br /> Cathodic Protection Rotary Type of Grout <br />—Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> &,Gt"x' r» <br /> Type of Pump h,a H, . <br /> PUMP REPLACEMENT: a State Work Done E <br /> PUMP REPAIR: <br /> Q State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 Locall <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 /> I WILL CALL FOR A GROUT INSPECTION _PRIOR TO GROUTING AND A FINAL INSPECTION. _ <br /> SIGNED TITLE: DATE: 41—.2 <br /> AW PEOT nTN ON REVERSE SIDE <br /> PHASE I FOR DEP RTMENT USE NLY <br /> A'PPL,ICATION ACCEPTED BY DATE <br /> ADDIvIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION <br /> � DATE PHASE III FINAL INSPECTION. �q <br />`�.NSPECTION BY <br /> INSPECTION BY DATE -fir 7y <br /> � 14 26 Rev. 9/78 t)1-70 Im <br />