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4 � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.z 9�Z,7_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,, <br /> (complete In Triplicate). <br /> z�-� <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 fc 9 /CITY/TOWN IJ <br /> Owner's Name Phone g Ste, i <br /> Address ; e <br /> / d U o: City — ' .�R.r�r, c&, Th. <br /> Contractor's Name Licensey �1 3 7--3-- Phone <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) :- NE'W_WEL�L_0 .,DEEPEN 0 ` RECONDITION [2- •-DESTRUCTIONrl <br /> " WELL CHLORINATION,O WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR M PUMP REPLACEMENT C� <br /> ,Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIME '. , : P'IT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE 'PIT OTHER <br /> PROPERTY LINE - PRIVATE D I�MESTIC WELL_` � +'PUBL_ICDOMESTIC WELL <br /> INTENDED USE tQ E OF WELL CONSTRUCTION SPECIFICATIONS <br /> --•I-ndustri al Cable Tool Dia. of Wel 1 :Excavation <br /> Domestic/private l Drilled Dia. of We11YCasing i <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation - Gravel Pack Depth of Grout Sea Lew <br /> Cathodic Protection LRotary Type of Grout, <br /> Disposal Other Other Information \I <br /> Geophysical Surface Seal ~Lnsta ed by: <br /> PUMP INSTALLATION: Contractor <br /> y Type of Pump /'Q. 0 <br /> PUMP REPLACEMENT: ❑State Work Done . <br /> PUMP REPAIR:. R State WoI-k Done - <br /> DE'STRUCTION OF. WELL: Well Diamet r iApproximate Depth <br /> Y Describe Ma eri a an Prote ure <br /> R <br /> I hereby certify_that�I ha_ve_pr_epa.ped_thi-s-appl i c-ati on=-and' that-the work-wi l-be donei n 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 WorkmaWs' '.Compensation <br /> laws of California.". <br /> I WILL CAL FO 'A GROUT NSPECTION aRnR TO GROUTING AM A'FINAL INSPECTION. `' , <br /> SIGN£D �f <br /> TITLE: i DATE: <br /> N ON REVERSE S DE <br /> R D PARTMENT QSE ONLY i <br /> PHASE I <br /> PPS LiCATION ACCEPTED BY DATE ffY:-Z72 <br /> ADDITIONAL COMMENTS: 11 _ <br /> PHASE II GROUT `INSPECTION �•. PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE E5)a <br /> FH 14 26 Rav_ 9/7R ki q/?R 2M <br />