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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,• Stockton, CA 95205 Permit No.2L-Z,5-3 � <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR Date Issued .1,,z4-72 <br /> WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ices 1 Year From Date Issued <br /> Complete 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 /> Ioaquin County Ordinance No .1862 and the .Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> 1 EXACTA STREET ADDRESSS Q . cr [,� CITY/TOWN <br /> Owner's Name Phone <br /> E Address City. <br /> Contractor's Name License Phone_ ff3ks=��93 <br /> 'TS CERTIFICATE OF WORKf1AN'S COMPENSATION INSURA?SCE ON FILE WITIf ,SJLHfl? YES <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR p -kPUMP.: REPLACEMENT Q <br /> v i <br /> DISTANCE"'TO"NEAREST:_ T-SEPTIC- TANK -- SEWER LINES PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE- OF WELL COfSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Ex <br /> cavation <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publ-ic Driven _ Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection , Rotary Type of Grout ' <br /> Disposal -Other Other Information E <br /> Geophysical �; - Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. / <br /> PUMP REPLACEMENT: M State Work Do47 <br /> ne <br /> PUMP REPAIR: Q State Work Done } ' <br /> DESTRUCTION OF WELL: Well ameter -- art- <br /> -�- � r � Approximate Depth � <br /> Descri�e 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 C R GROUT INS CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN <br /> TITLE: DATE: - �.-Z <br /> i DR W PL T PL N ON REVS E SIDE <br /> PHASE I FOR DEPARTME T USE ONLY <br /> APPLICATION ACCEPTED BY DATE 6 <br /> ADDITIONAL COMMENTS: ZZL <br /> PHASE II GROUT INSPECTION • PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S" -767y � <br /> EH 1426 Rev. 12-77 Cl��-7Q 'JM <br />