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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave, , Stockton., CA 95205 Permit No. :1Ss�3 <br /> Telephone: (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,�y,7g' <br /> p <br /> • � � � �1y�� 7$ <br /> ('Complete In Triplicate), ° „ ©72-- y�D- 2-0 <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 /> Joaquin County Ordinance No. 1862-and the Rules and Regulations of the San Joaf� in Local Health <br /> District. :(�.5'7r'r- 74J .Q� hs / <br /> EXACT STREET ADDRESS i'0�,, CSU (,(/ ��0, W° SCI Y7TOWN <br /> Owner's Name �, . Phone <br /> a <br /> Address— C40 <br /> C' _ cit���._ eeram <br /> Contractor' s Name License# Phone <br /> w <br /> I5 CERTI_FICATE OF WORKMAN'S COkMPENSATION INSURANCE--_ON FILE WITH SJLHD? YES - - - 0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION i _ � �, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT � <br /> PUMP INSTALLATION [.I PUMP REPAIR Q PUMP REPLACEMENT [:] ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . ... _ PIT PRIVY +� <br /> SEWAGE DISPOSRL FIELD CESSP�1- /SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC 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 Wel.1 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 Other Other Information `r1 <br /> GeophysicalM: Surface Sean Installed by: <br /> PUMP- INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> >*�. <br /> PUMP REPLACEMENT: r]State Work Done - i <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter " Approximate Dept mo �� <br /> Describe Mater a1 and Procedure—It <br /> r <br /> rQ t' o wieem � o <br /> I hereby certify that I have prepared this application and Vhat 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 Califor ia. <br /> I WILL L FOR A ROUT INSPECTION PRIOR TO GROUTING -AND 'A FINAL INSPECTION. <br /> SIGNE TITLE: DATE: 7�3 <br /> R PL PLTN ON RE 'E SE SIDE) <br /> R EP RTMEN US -ONLY <br /> PHAS I <br /> APPLICATION ACCEPTED BY �L� <br /> DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> EH 14 26 Rev. 9/78 9/78 2M i <br />