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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave._,_5tockton, CA 95205 Permit No. ,7,9 5o8 <br /> Telephoned (209) 466-6781 <br /> I Date Issued ,5 -? <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires l 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 />.'oanuin County Ordinance No. 1862 and the Rules and Regulations of the ;San Joaquin cal Health <br /> DJstrict. <br /> ,- <br /> EXACT STREET A!lRESS CITY/TOWN <br /> p5' <br /> /17 <br /> Owner' s Name Phone <br /> Address Q City �I <br /> Contractor' s Name License# D Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOM I SURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEVWE+L t DEEPEN 0 RECONDITION ® DESTRUCTION[] <br /> WELL 'CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERS] <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT ❑ �� <br /> I <br /> DISTANCE TO NEAREST: SEPTIC .TANK /� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD IjW CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool =D: a. of Well Excavation <br /> _Domestic%private Drilled `^Dia.` of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Ila 0- <br /> Irrigation Gravel Pack Depth of Grout 1 17?1 _ 4 <br /> Cathodic ,Protection �__ Rotary Type of Grout ._ >. <br /> Di sposal F Other Other Inforfmati:ori <br /> Geophysical Surface Seal Instal ed b <br /> .PUMP INSTALLATION: Contractor y M.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work -Done ,; } <br /> PUMP REPAIR: Q State Work Done + 3 <br /> DESTRUCTION OF WELL: Well Diameter Ap.proxAmate Depth <br /> Describe Material and Procedure <br /> I hereby certify that .1--have prepared thi's'4app1~i eati on'a and that" the work. wi 11. 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 'CALL FOR A GROtT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 5/ <br /> DR W PLOT 17LAN ON REVERSE 5iDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii ROUT I`N SPECTION i PHASE III FINAL INSPECTION <br /> INSPECTION BY DATES INSPECTION BY ( . DATE 1 <br /> - 1 /78 2M_ <br />