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--S-AN JOAQUIN .LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. . Hazelton Ave. , Stockton, CA, 95205 Permit No. 7 <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL ONSTRUCTION OR PUMP PERMIT Date Issued /-_3 -2 9 <br /> This Permit Ex fres 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT. STREET ADDRESS �' L_�G11.57- T46W CITY/TOWN J—.G'!>/ _ <br /> Owner's Name Phone <br /> Address City 0 <br /> Contractor' s Name �riS n! .ter 121C.�2 Li cense#*037�� hone 759--�3`7 <br /> IS CERTIFICATE OF WORKMAN'S COM;PENSATIOIN INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (YCheck) : NEW WELL❑ DEEPEN Q LRECONDITIONO J DESTRUCTIONED <br /> WELL CHLORINATION p WELL ABANDONMENI ED OTHER 0- <br /> PUMP INSTALLATION" El PUMP' REPAI'R'O PUMP REPLACEMENT Q " <br /> DISTANCE TO NEAREST: SEPTIC TANK 4e SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ OTHER <br /> t PROPERTY LIN RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF. WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ACable Tool Dia. of Well Excavation / <br /> Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/public Driven Gauge of Casing 67 <br /> _Irrigation Gravel Pack Depth of Grout Seal ----- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 1--- <br /> Geophysical Surface Seal Instal ed by- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: (State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant( <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 F R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: <br /> DR W FLUI PLAN ON REVERSE SIDE <br /> FOR' DEPARTMENT USE .-ONLY �f <br /> PHASE I � .- - . _�. . <br /> APPLICATION ACCEPTED BY DATE/ ' 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE TI N PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY (' � _ DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />