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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> raIOFFICE 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 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 Re ulations of the San Joaquin Local Health <br /> "istrict. � 15 y2�� <br /> EXACT STREET ADDRESS 7 f'61 V &0. /W0Z>AE Q er. CITY/TOWNOwner's Name Name (�co K A4 o -'T L'a H.rT Phone C77/ <br /> Address— 1'2 7 Z^; Tip C i t � C- <br /> Contractor' s Name & 2 L/a CT./� I C- License#/77J'00 Phone gs J-- l-Tf <br /> IS CERTIFICATE OF WORKMAN'S CONiPENSATI011 111SURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ Q) <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT El <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing e <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 by: <br /> PUMP INSTALLATION: Contractor .zT -XCXcTi' , <br /> Type of Pump SKaA#Jrx r)a c.K H.P. /jL <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe Material and 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 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 INS ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: o0 <br /> �'or DATE: �8 -_- <br /> (DRAW PL T PL N ON REVERSE IDE <br /> FOR DEP RTMEN SUSE ONLY <br /> PHASE I c <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />_EH 1426 apv_ 12-77 _ - 1/78 2M <br />