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�- - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -iQg�. FQ FICE_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 `f <br /> (Complete In Triplicate) AILAKI <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 'and/or instal? '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 'yc � / �,e�®GtS � CITY/TOWN 01/ 7� <br /> Owner' s Name �ie(�/ G Phone—3c;;qO_� <br />_Address City& e6: :J� <br /> Contractor' s Name c'(40 % <br /> ,cense#,__23/2tS"Phoneg37—,S7(; <br /> IS CERTIFICATE OF WORK"IAN'S CO"IPE1117SATIO'N I"�SURA'`10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check)... NOW ELI DEEPEN.❑; --RECON'DITI-ONrC].-- -DESTRUCTIONd -- <br /> WELL CHLORINATION 0 WELL ABANDONMENTED OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT CI <br /> DISTANCE TO NEAREST:"' SEPTIC.TANI� SEW �R LINES��PIT PRIVY iVpXJE*r <br /> SEWAGE DISPUSALFIFIELD. CESSPOOL/SEEPAGE„ PIT OTHER <br /> 3 PROPERTY LINE - PRIVATE DOMESTIC WELLS PUBLi DOMESTIC WELL - <br /> INTENDED USE ` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t,- Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> —Irrigation Gravel- Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information �— <br /> _Geophysical Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 3 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑State Work Done <br />}DESTRUC-!-0N--O-F- WELL: We1,1_D_4-ame Ge-r_. Approxi mate Depth <br /> W Describe Material and Procedure - <br /> F� <br /> I hereby certify that I have prepared this application and that the work will be done in accoonc <br />. with. San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin �al <br />- Health District. !dome 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 . h manner as to become subject to Workman 's Compensation <br /> 1 alifornia . ” <br /> I WI CALL F R GR N CTION PR OR TO GROUTING AN INAL I CTION. F <br /> SIGN TITLE- DATE: -3 <br /> DRWPLTPLNON RESRE <br /> FOR DEPARTMENT SE ONO <br /> PHASE I <br /> APPL'.CATION ACCEPTED BY �' - DATE <br /> ADDITIONAL COMMENTS . i <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />.TNSPECTION BY DATEINSPECTION BY <br /> DATE <br /> Lli 14 26 Rev. 9/78 5/79 2" <br />