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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE-: 1601 E. Hazelton Ave. , .Stockton,, CA 95205 Permit No. <br /> Telephone: , (209) 466-6781 Date Issued ,-z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT _ <br /> '(CompleterI'n Triplicate)` ' <br /> Application is hereby made to the San Joaquin' Local Health, Di.str;ict fora 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. r <br /> EXACT STREET ADDRESS . - "t CITY .TOWN CSS <br /> Owner's Name /(4J n J� a. a x Phone <br /> City <br /> Address: ek, <br /> AJ,,Ve. <br /> Contractor's' Name License# ` 3- Phone --x � <br /> FS CERTIFICATE OF WORKt1AN'S CO E SATION INSURANCE ON -FILE WITH SJLHD7 YES 0 <br /> TYPE OF WORK'(Check) : ,NEW WELL❑ DEEPEN ❑ # RECONDITION ® DESTRUCTION[n. <br /> w ,:WELL CHLORINATION 0WELL ABANDONMENT t3OTHER 0 ... �------ <br /> "PUMP INSTALLATION_.P' PUMP° REPAIR❑ PUMP REPLACEMENT ❑� <br /> ' DISTANCE TO NEAREST: ySEPTIC TANK A SEWER LINES PIT PRIVY � <br /> . ,SEWAGE DISPOSAL FIELD CES�6L)SEEPAGE PIT OTHER <br /> -, PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEd USE. r tit- TYPE OF WELL �. �? CONSTRUCTION SPECIFICATIONS . <br /> k' Industrialw Cable Tool Dia. of Well Excavation .. <br /> _Domestic/private Drilled Dia. of 'Well Casing _ t <br /> Domestic/publico . 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 Insta ed b .m,. <br /> PUMP INSTALLATION: f� Contractors e.:e <br /> ! Type of Pump l H. 2.-- <br /> PUMP REPLACEMENT:. Q State Work Done <br /> ` PUMP fit::. ._ SState Work Done ''t" <br /> DESTRUCTION OF :WELL: Well Diameter Approximate Depth_ <br /> ' Describe MateFi-al and Proce ure <br /> I .hereby certify that I have prepared this application and °that the work will bei done in accordan <br /> with San Joaquin County Ordinances , State .Laws , and Rules and Regulations of the-San Joaquin Loca_ <br /> tHealth District' Home owner or licensed agent's signature certifies the following: . n - <br /> [ "I certify°that in ,•the performance of the work for which this permit­is 1ss.ued,.. I shall ' <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California."' ' <br /> - <br /> I WILL CALL FOR A GROUT INSPEC ION PR- R TO GROUTING AND A'FINAL-INSPECTION. <br /> SIGNE '-� ITLE: a� DATE: 7-a <br /> PL PLLIN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> ° ADDITIONAL COMMENTS: <br /> x 7 7- <br /> -PHASEAI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY !' DATE INSPECTION BY DATE _a <br /> {EH 14 26 Rev.. 9/78 _ 9/78- 2M <br />