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` " - ' SAN JOAQUIN LUCAL HEALIH UISIklCl <br /> FFICE USE: 1601 iazelton Ave. , Stockton, CA 9, 5 Permit No. 7� - 559 <br /> Telephone: (209) 466-6781 s <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 31-? <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 L7 ? 'i CITY/TOWN <br /> Owner's Name A- Phone <br /> Address -72 J �1 .-� <<" City <br /> Contractor's Name 7- :2-z:�:/ License /1.37j-1' Phone 41�6i J6 <br /> IS CERTIFICATE OF WORKMAN'S C01,1 NATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN O RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION �! PUMP REPAIR O PUMP REPLACEMENT ❑ <br /> DISTANCE N NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP�L/SEEPAGE PIT OTHER <br /> � & 7y_��ZPROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Xo H.P. iy <br />'UMP REPLACEMENT: [] State Work Done <br />'UMP ( State Work Done /m-4,/ p <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordant <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 /> WILL CALL FOR A GROUT INSPECTIO PR OR-- 0 GRIDUTING AND A FINAL INSPECTION. <br /> IGNED C ' -~'" ITLE: r-e-c./ DATE: 1 <br /> _� <br /> PLOT PLAN ON REVERSE SIDE <br /> OR DEP RTM NT USE ONLY <br />-HASE I <br /> PPLIC/lTION ACCEPTED BY DATE - d 7 <br />-DDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> 4SPECTION BY DATE INSPECTION BY DATE 6 y 7 <br /> q 14 26 Rev. 9/78 / 9/78 2M <br />