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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ICE USE: 1601 E. Hazelton Ave. , Stockton, CA .95205 Permit No.7p_y� <br /> Telephone: (209) 466-67'81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /-9 2f- <br /> ('Complete In Triplicate), <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit" to construct <br /> and/or install the work herein described. This application is made in compli-ance with San . - <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of .the- San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSr <br /> s J: Amde� CITY/TOWN ' r7►; <br /> �— <br /> Owner's Name Phone <br /> Address. _ i�4 x Pz City <br /> Contractor's Name C y License# L4.37z�Phone <br /> IS CERTIFICATE -OF WORKMAN'S CO";P SA ION INSURANCE ON FILE WITH SJLHD? YES T 0 <br /> TYPE OF WORK (Check) : " NEW WELL 0 DEEPEN ❑ RECONDITION DESTRUCTION� <br /> i " WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER { <br /> f 14PUMP INSTALLATION M PUMP REPAIR® PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: , SEPTIC TANK SEWER LINES .,.. PIT PRIVY. j <br /> ,;SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ v <br /> Industrial Cable Tool Dia. of Well Excavation <br /> r _Domestic/private Drilled Dia. of Well Casing p <br /> —Domestic/publ ic' � _-- -Dri-venom - Gauge of Casing - ."%-. <br /> - Irrigation 1 <br /> 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: ,iContractor <br /> ..Type of PumpAL H. . <br /> PUMP REPLACEMENT: p State Work Done F - . <br /> PUMP REPAIR: .y - - <br /> QState Work Done &- <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 accordant <br /> , with San Joaquin County Ordinances, State Laws , and Rules .and. Regulations of the San Joaquin tocal <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 /> k not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California.. <br /> I WILL CRL FOR A GROUT) INSPECT I GROUTING 'AND A� FINAL INSPECTION. i <br /> SIGNEDATE ITLE:k . <br /> RAW L ON REVERSE SI E <br /> PHASE I H <br /> FOR DEPARTMENT USE ONLY . <br /> - -+ <br /> PPS LICATION ACCEPTED BY. DATE 7 <br /> ADDITIONAL COMMENTS: Al <br /> ` PHASE. II GROUT INSPECTION <br /> ,,INSPECTION BY DATE PHAS II F N INSPECTION <br /> INSPECTION BY DATE 6 -,z Yy <br /> SEH 14 26 Rev. 9/78 _ 9/78 " 2M <br />