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SAN JOAQUIN LOCAL:;BE,ALT,H DISTRICT <br /> FM FFICE USE: 1 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permit NO- 22-370 <br /> Telephone: (209) 466•-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - �? . <br /> (tomplete In Triplicate) <br /> r <br /> Application is hereby made to the San Joaquin Local Health .District for a permit to construct <br /> t 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'( CITY/TOWN S-rocToid <br /> + <br /> Owner's Name Phone :FfO-jar � <br /> Address Q Gi tY ..S <br /> Contractor's Name 4 License# Phone <br /> I ; <br /> IS CERTIFICATE OF WORKIIAN'SICOMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO. <br /> TYPE OF WORK '(Check) : NEW WELL 0 DEEPEN ❑ RECONDITION Q DESTRUCTION � <br /> F <br /> WELL- CHLORINATION p WELL ABANDONMENTED OTHER( <br /> °PUMPIINSTALLATION Q PUMP REPAIR CI,-- - PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAFIELD CESSPOOL/SEEPAGE Pte^' . . OTHER <br /> PROPERTY LINE - PRIVATED MO ESTIC WELL PUBLIC D MESTIC WELL <br /> - INTENDED USE TYPE OF.WELL... CONSTRUCTION SPECIFICATIONS <br /> „Industrial Cable Tool Dia. of Wel Excavation <br /> 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 57.7- <br /> PUMP <br /> :PUMP INSTALLATION. Contractor <br /> Type 'of Pump H.P. <br /> . PUMP REPLACEMENTSt <br /> : ;Iate Work Done - - - � --•---� <br /> w�- <br /> PUMP REPAIR: ❑State Work Done <br /> ` DESTRUCTION OF WELL: Well 'Diameter 'r Approximate Depth /pp ";o-- <br /> Describe material and Procedure_,?c/- <br /> 4,p 4,e- <br /> ! I hereby certify that I have prepared this application and that the work will be done in accordant <br /> twith' 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 CA FOR A T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SSGNEDTITLE: - DATE: ' <br /> DR PLOT PETWON REV E SE SIDE <br /> - FOR DEP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS F L INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION B DATE �Zt� <br /> EH 14 26 Rev. 9/78 " - 9/78 "' 2M <br /> �. <br />