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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �FIICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 31-72 <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 madein compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin -Local- Health <br /> District. <br /> EXACT: STRFET ADDRESS` 6 4� CITY/TOWN <br /> Owner's Name _ _ - Phone lcrr-dam <br /> Address City <br /> Contractor' s Name ,� �.� �.s' — Li cease#��'L t�P Phone. <br /> 27 Z77 <br /> IS CERTIFICATE OF WORKMAN'S 'COFfPENSATIO ! INSURA?ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF 'WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ 4a <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> fA 4 PUMP INSTALLATION .ZI PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE "ITYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 . 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 Seal <br /> Cathodic Protection q.--Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical F Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor' <br /> Type 4of Pump <br /> UMP REPLACEMENT: _[] State Work Done <br /> PUMP' REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ^� <br /> E :I <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 /> iHealth District. Home owner or licensed agent' s signature certifies the following: <br /> i "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. " �z <br /> I WILL CALL FOR A GROU INSPECTION P IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED—a- ,:L-�— ?/ TITLE: # DATE: 3 <br /> DR W PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I a _ <br />' APPLICATION ACCEPTED BYM-M DATEJr—S — 7 <br />` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3--S--Z7- <br />-PH <br /> --S —Z"FH 1 A9A Only 19_77 , � Ou <br />