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6 i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No:�L <br /> Telephone: (209) 466-6781 = <br /> Date IssuedMAY $2 4 1978 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate w <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 /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ..30CITY/TOWN <br /> Owner's Name Phone c�,.,7JJJO <br /> Address Ci ty y d t" <br /> Contractor's Name , ---- ,� License# � Phone_ <br /> ':S CERTIFICATE OF WORKMAN'S C0111PENSATIO`1 I11SURA1,10E ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION Q DESTRUCTION EJ ~ <br /> WELL CHLORINATION 0 WELL ABANDONME.V Q. OTHER rJ ` <br /> PUMP INSTALLATION Q PUMP REPAIR 'PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY (f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY 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 Seal <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 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work DoneA .V_J2 D p A p qr A gl_ <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 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 .CA L FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:�j=/72� <br /> R W PL PLAN ON REVERSE SID£ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP£C ION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE, INSPECTION BY DATE�•. <br />_EH 1426 Rev- 12--77 1_/ 2M <br />