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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �6 1 <br /> FOR <br /> FFICE USE: 1601 E lazelton Ave. , .Stockton, CA S `5 Permit No.99.a87 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued4_2-79 <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 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. r <br /> EXACT STREET ADDRESS 431q (Jnw 1�ir[��� Zl( CITY/TOWN �t�r <br /> Owner's Name PhoneF,3�=E`Izr <br /> Address � _d- - �Q,1 City ;7�r <br /> Contractor' s Name LicenseBn/6c,.;' Phones-, <br /> `S CERT_IFICATC OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF 14ORK (Check) : NEW WELI�6-� DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT O OTHER ❑ <br /> POMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -• PRIVATE D7ESTIC 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 Sea <br /> Cathodic Protection `-Rotary Type of Grout <br /> Disposal 7 Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 44 pi % A� r�VE�..� <br /> Type of Pump il .Y— <br /> PUMP REPLACEMENT: ❑ State .Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materiaand Procedure <br /> I hereby certify that .I have prepared this application and that the work will. be done in accordan( <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. " .11 <br /> I WILL CALL A , ROUT SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 2-7 <br /> (DRAW PLU PL N ON REVE S SID <br /> R' DEP RTMEN _. USE ONLY <br /> PHASE I <br /> APPLIC ACCEPTED BY � J DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FH idgr Rp,, 10-77 l /7A 9M <br />