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-- y/ SAN JOAQUIN. LOCAL HEALTH DISTRICT <br /> ' EOR QFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Z y_ .z <br /> Telephone: (209) 466-6781 <br /> jf <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued J-g3.,..--� <br /> x (eomplete , 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. f <br />► EXACT STREET ADDRESS CITY/TOWN r_&'f2nE"-as <br /> ?Owner's Name__MffS. Phone 2� Z <br /> t 'Address 21 City cA ZE Al <br /> {Contractor's Nameaugmg /� ,License#aA� Phone <br /> ?I'S CERTIFICATE OF WORKMAN'S COMPENSATION INSURA6CE ON FILE WITH SJLHD? YES 0. <br /> ?TYPE 'OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION DESTRUCTION d <br /> WELL CHLORINATION pWELL ABANDONMENLE3_OTHER F-3 - -_' <br /> PUMP 'INSTALLATION Jj.P€JMP REREPAIR O--. PUMP REPLACEMENT a — <br />` DISTANCE TO NEAREST: ;SEPTIC TANK SEWER LINES` PIT PRIVY <br /> -SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC DOMESTIC WEL .� <br /> k INTENDED USE" TYPE OF.WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable 'Tool Dia. of Well Excavation .� <br /> Domestic/private Drilled Dia. of Well Casing s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ti Gravel Pack Depth of Grout Seal-� <br /> —Cathodic Protection Rotary Type of Grout •---. -- - <br /> Disposal Other Other Information <br /> F Geophysical Surface Seal Install—id—by. <br /> PUMP INSTALLATION_: Contractor w <br /> Type of Pump . cr' H.P. <br /> PUMP REPLACEMENT: QState WorkDone4, ; , <br />.' PUMP REPAIR: O State Work Done <br /> rgESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater,i-a an Proce ure - <br /> I hereby -certify that I have preparedythis application and that the work -will be done in aceordanci <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 /> I WILL CALL FOR A GROUT INSPECTION PRIOR TOGROUTI`NG"ANDA FINAL INSPECTION. ` <br />.SIGNED = TITLE°: DATE: / zzz <br /> PLAN � <br /> DRAW P T <br /> R DEPARTMEN USE ONLY <br /> SIDE <br />:PHASE I .._.f:�. -y. . . __.- <br /> PPLI ATTON-ACCEPTED•-B'Y y <br /> _ _DATE- - �.,. .. ;7. <br />'ADD-ITiONAL., COMMENTS: -- A= <br /> I PHASE II GROUT INSPECTION PHA E IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 3 DATE - -�q <br /> fH 14 26 Rev. 9/7$jTrC__ 9/78 2M <br />