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P SAN JOAQUIN LOCAL �HEALTH DISTRICT <br /> FFICE USE: Ib01 E. Hazelton Ave. - Stockton, CA 95205 Permit No. d-- <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION Date Issued //—/3--7� <br /> ST UCT.ION OR PUMP PERMIT <br /> 1 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <br /> Application is- hereby made to the San Joaquin Local Health District f <br /> q t or 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 /> t District. <br /> EXACT .STREET ADDRESS. .(, - CITY/TOWN <br /> a m e L Phon -`3�r– s' .3 <br /> Address �' r City . <br /> Contractor' s Name j License&i 9 Phone $'� o <br /> IS CERTIFICATE OF WORKMAN'S dOM'RENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL`Z DEEPEN ❑ RECONDITION [] DESTRUCTION[] <br /> WELL CHLO'R'INATION Q WELL ABANDONMENT 0 OTHER 0 <br /> _ P.UMP.,,..IPS.TALLAT.ION-.DQ.—PUMP.REPAI.Rd,.:. PUMP REPLAC.EMENT_Q_ <br /> DISTANCE TO NEAREST: SEPTICITANK ` SEWER LINES PIT PRIVY <br /> f SEWAGE) DISPOSAL IELD l,#p CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE!a RIVATE DOMESTIC WELL!^�_ PUB.LIC DOMESTIC WELL <br /> INTENDED �'' <br /> USE TYPE OF WELL CON ST-RIJ'CTJON SPECIFICATIONS <br /> Industrial Cable Tool- /Dia. of Weli Excavation_. /3�a <br /> :,_Domestic/private Drilled Dia. of Well Casing, <br /> Domestic/public Driven , .t Gauge of Casing .s bvs'r l/CF <br /> Irrigation =Gravel Pack , Depth of Grout —Se—a-1 :�o✓ t <br /> Cathodic Protection Rotary ' Type of Grout `15g,L=Z'• oT� e T <br /> Disposal Other k Other Information A �� .� Pik <br /> Geophysical µw I Surface Seal Installed b' .• <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump .P:, <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: � `��� �-r-•--�- _" <br /> QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter r ��"` � Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and th'AV-thejwork 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.�i n:.'the-.ver`;formance*of;the work jfor which this permit i s 'issued, 1 shal l <br /> not employ any person in such manner as to becoW subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CAL FOR A GRO T INSPEC1.1U. 1vvPR10R TO GROUTING AND A FINAL INSPECTION.. <br /> SIGNED r TITLE: DATE;; <br /> DR W PLOT PL N ON REVERS STD <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE I/ 131,J> <br /> I <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION iPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 6 INSPECTION BY -�• DATE <br />,FH 142fi Rav_ 19-77 ! r� .- o •,,� <br />