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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton. Ave. , Stockton, CA 95205 Permit No. 7 9- G Y _ � <br /> 4e Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued L, -,;2-5-79 <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 /> Joaquin County Ordinance No. 1862 and the Rules and. Regulations. of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSLd <br /> CITY/TOWN <br /> Owner' s Name 15eAAL Phone , <br /> Address n. City. <br /> Contractor' s Name /Q s e �C� ' Li censef;2!%& Phone — v <br /> IS CERTIFICATE OF WORKMAN'S COFfPENSATIO"S INSURANrT 0 FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL[A DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ . <br /> PUMP INSTALLATION �' PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK jb®-1SEWER LINES Z� �' PtT PRIVY - �- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIMATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /r <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public . Driven Gauge of Casing Z2 <br /> Irrigation _Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _Rotary Type of Grout C SAW <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b , <br /> PUMP INSTALLATION: Contractor ift <br /> Type of Pump 6 H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> V <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe' Material and Procedure <br /> I hereby certify that I. have.p.r-epared _this-ia.pplication and that the__work. w•i_ll:_b.e_done in accordance <br /> with San Joaquin County Ordinances ,. State Laws , and-Rules n d 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 PRIOR -TO GROUTING AND A� FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � - <br /> ADDITIONAL COMMENTS : 19 0 <br /> PHASE II GROUT INSPECTION ''PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - 2 d INSPECTION BY n. DATE 9 z3 <br /> A- <br />