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SAN JOAQUIN LOCAs. HEALTH DISTRICT .��.. <br /> FFICE USE; - — 1601 E. Hazelton Ave. , Stockton, CA 95.205 Permit No.i IT <br /> Telephone: (209) 466-6781 <br /> APPL`-ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-s,/-?2I <br /> (Complete In Triplicate) <br /> Application is hereby made to 'the San Joaquin Local Health District fora permit to 'tonstruct <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 CITY/TOWN Ski, <br /> Owner's Name Phone <br /> Address ' / CitYZA4"€�4f 9'1 <br /> Contractor's Name, ,rfzo License# Phoney <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSAT MM INS RANCE ON FILE WITH SJLHD? YES 0 <br /> - - - _ <br /> TYPE OF .WORK (Check) : - NEW WELL Cl DEEPENRECONDITION DESTRUCTION rl Y <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER n <br /> ' PUMP • INSTALLATION 0 PUMP REPAIR+] PUMP REPLACEMENT [] - <br /> DISTANCE TO NEAREST: SEPTIC 'TAN _f_ SEWER LINES-So,�-trPIT PRIVY <br /> SEWAGE DISPOS8L1FIELD 1 CESSPOOL/SEEP GE PIT OTHER <br /> . PROPERTY LINEfv +PRIVATE D ESTIC WELL PUBLIC DOMESTIC WELD--� <br /> INTENDED.USE TYPE-OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial v =_Cable Tool Dia. of Well Excavation ZZ/Uv <br /> Domestic/private. An Drilled Dia. of Well Casin <br /> o,4_4 <br /> Domestic/public YII Driven Gauge of Casing �1 1 <br /> _Irrigation it Gravel Pack Depth of Grout Seal 44 �---- <br /> Cathodic Protection It Rotary Type of Grout <br /> Disposal E Other Other Information _ <br /> Geophysical Surface Seal Installed - --, —�' <br />)UMP INSTALLATION: Contractor <br /> Type of :Pump H.P. <br />?UMP REPLACEMENT: ❑State Work Done Y <br />?UMP R-EPAIR:, QState Work Done <br />]ESTRUCTI-ON- OF' WELL 'Well Diameter Approximati-be pth <br /> Describe MateFial and Proce ure k <br /> I hereby certify that - I have prepared this application and that" the work will be done in accordance <br /> v;ith San Joaquin- County Ordinances, State Laws , and Rules and Regulations of the -San Joaquin- Local, <br /> lealth 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 /> f laws of Californi ." <br />[' WILL CALL F GR T APDX PRIOR TO GROUTING AND A"FINAL INSPECTION. <br />';IGNED TITLE:; - DATE: <br /> i P T N ON REVER E E <br /> OR DEPARTIJENT USE, ONLY <br />'RASE I _ . <br /> iPPLICATION ACCEPTED BY :. - ", <br /> . Z, 4S_ , . ; DATE77 <br /> 0DITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION <br /> PHASE III ' FINAL INSPECTION <br /> NSPECTION- BY DATE INSPECTION -BY DATE I- ��iZ <br /> H 14 26 Rev. 9/78 9/78 2M <br />