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SAN JOAQUIN' LOCAL- HEALTH DISTRICT <br /> FFICE USE: " 1601 E. Hazelton Ave. , Stockton CA 95205 Permit No-7j- j6)/-4 ;?- <br /> 11c <br /> o. <br /> Tele hone: �. _. _. � � -- I ,y ,Z <br /> �. P (209466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUMP. PERMIT Date Issued 7— <br /> This Permit Ex, e Issued, <br /> fres 1 Year From Dat ` <br /> Complete „In Tripli <br />{ Application is her by made to the 'San Joaquin- Local Health District for a permit to construct <br /> ,and/or install 'the work herei � described. This .application is :ma'de in compliance with San <br /> ,oaquin .County Ordinance No- ;1862 and the Rules and Reg ations of°-the San Joaquin Local Health <br /> str�c.t. <br /> EXACT STREET ADDRESS <br /> CI TY <br /> Owne 'r's Name - .- . � _ � Phone <br /> Address <br /> City <br /> Contractor's Name - `-t-icense�&/ Phon � �Q <br /> '' 1 l <br /> IS CERTIFICATE OF WORKMAN'S CnmvPNSATIOt! I"dSURAl�CE OP! FILE lrlITH SJLHD? YES �� r <br /> i0 <br /> TYPE OF WORK '(Check}t: NEW WELLe DEEPEN ❑ RECONDITION ® DESTRUCTION[� <br /> ' WELL CHLORINATION 0 WELL ABANDONMENT p OTHER❑ <br /> PUMP INSTA_LLATION-0_ PUMP REPAIR❑ PUMP REPLACEMENT ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC DANK SEWER LINES PIT PRIVY <br /> SEWAGEFDISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTICRWELL <br /> FINTENDED USE TYPE OF WELL <br /> Industrial :T CONSTRUCTION SPECIFICAT 0 <br /> Cable Tool rl Dia. ofiWe Excavation <br /> omestic/private Drilled I.-Dia.--of Well—Casing f <br />___,_Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic !Protection Rotary : ` Type of Grout <br /> Disposal r 0the\ Other Information <br /> Geophysical i Surface Sear Installed <br /> PUMP INSTALLATION: Contractor <br /> /., Type of., Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done - <br /> PUMP�REPAIR: ❑State Work Done <br /> F <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia an Procedure Approximate Depth <br /> f} <br />[ hereby certify that I have prepared this application and that the work will be done in accordance <br /> vith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth District. Home_ owner or licensed agent's signature certifies the following: <br /> "I certify that 'ih the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to becom Jec Workman's 'Compensation <br /> laws of C lifornia. " <br /> WILL CAL OR A GROUT INSPE N PRIOR TO GROUTING A FINA IN PE ON.. h <br /> IGNED .TITLE: D E <br /> DRAW PLOT PL N ON R E SIDE <br /> RASE I FOR DEPARTMENT ,USE ONLY <br /> PPLICATION ACCEPTED BYt <br /> DDITIONAL COMMENTS : DATE Jam.—��✓ <br /> PHASE II GROUT INSPECTION PHASE I N L INSPECTION <br /> 4SPECTION BY;5� DATEapi 2L. INSPECTION BYr <br /> DATE �G 9 <br /> 4 1426 Rev. 12-77 __ ”. _ (`Z3 - -- - <br />