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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. t"7 9-g/J <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCT &VPT <br /> Issued <br /> (Complete Iri Trip1i } <br /> r2 ., x;13 i9T9 <br /> IApplicat-ion is hereby made to the San Joaquin Local Health DNfor a permit to construct <br /> and/or. instaTl the work herein described.. This applicati-o A fiance with San <br />° Joaquin County Ordinance No. 1862-and the Rules and. Regulap oaquin Local Health <br /> District. <br /> EXACT'STREET ADDRESS eVhzl- CITY/TOWN /�r.�c� <br /> Owner's Name Phone az,'— 4 q,57 <br /> Address _. City r is <br /> Contractor's Name License# PhoneE:�� !7 -2LIQ <br /> Y P <br /> SIS CERTIFICATE OF WORKMAN'S COMPENSATION INSUVANCF ON FILE `WITH' SJLHD? YES 0� <br /> f <br /> TYPE'.OF WORK (Check) : NEW WELL M DEEPEN,M RECONDITION.-M DESTRUCTION[y <br /> -JELL CHLORINATION 0 WELL -ABANDONMENT 0' OTHER 0 <br /> PUMP INSTALLATION 0. PUMP REPAIRCp,, PUMP REPLACEMENT L <br /> f <br /> DISTANCE TO NEAREST: �.'SEPTIC TANK S SEWER LINES - PIT :PRIVY <br /> SEWAGE DISPOSE � FIELD CES S QL/SEEPAGE PIT _.OTHER —T <br /> PROPERTY LINE✓✓ tPRIVR E Do*STIC: WELL,:�'" PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industria Cable Tool,.-� Dia. of Wel Excavation if f / .i <br />#De omestic/privatDrilled Dia. of Well Casing kv <br /> Domestic/public DrivenGauge of 'Casing <br /> Irrigation GravelIPack Depth of Grout Sea <br /> Cathodic Protection Rota y Type of Grout - <br /> ' Disposal .-'` Other Other -Information y` <br /> Geophysical Surface Seal Insta ed b <br /> PUMP INSTALLATION:. Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State4Work Done c. <br /> PUMP Ott <br /> ate r J <br /> . ate Work Done k <br /> DESTRUCTION .OF WELL: Wel..l "Diameter Approximate Depth . <br />} Dd'scribe MateriaF ana Procedure <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 Locale <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 CA OR A T I P CTION PRIOR TO GROUTING AND V FINAL INSPECTION. <br /> S4GNED i <br /> TITLE: DATE: <br /> D L77TEW ON REVERS IDE r` <br /> FOR DEPARTMEl�-�--/USE ONLY l� � <br /> PHASE I - <br /> APPLI ATION ACCEPTED BY _ DA E . u/ Z <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION a , PHASE III FINAL INSPECTION <br /> INSPECTION BY <br /> DATE F SPECTION BY DATE r <br /> LH, .14 26 Rev: 9/78 <br /> ;. -... . ... ._....... _ .. T . . ". �- 9/78 <br />