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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �_ �U-2 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,5-1.5-7 <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 aGGO CITY/TOWN <br /> Owner's Name �? z-� erw�h er'e Phone <br /> Ad d r-e s sC i ty, <br /> Contractor's Name—. S-11,-7 r L^ ,,��„� License#/13-7st"Phone _ 6,2.- 7&74 <br /> IS CERTIFICATE OF WORKMAN'S CO"IPENSATION INSURANCE ON FILE WITH SJLHD?' YES )C NO <br /> �. <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑. RECONDITION [3 DESTRUCTION[n <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION P7 PUMP REPAIR❑ PUMP REPLACEMENT [� b <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/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 We 1 Excavation <br /> x _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 Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractors v <br /> Type of Pump K H. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP R92#pg: Q State Work Done <br /> rf <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Proce ure <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 /> 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 GROUT INSPECTION P IO TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE / 0 ITLE: DATE: dl7l <br /> D P L ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYZVICDATE 1////79 <br /> ADDITIONAL COMMENTS: xc <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 5 z9 7 <br /> EH 14 26 Rev. 9/78 9/78' <br />