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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P�2FFICE USE: 1.601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6 - 8-79 <br /> T t ,J , .. (,Complete In Triplicate) <br /> . � 33,o 3-2 <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 ADDRESSYo M/l.e e Mehe AI/ S ivp CITY/TOWN / Aai/tee <br /> Owner's Name `� --_ 3 –� <br /> Phone9 l'3„e,�- - -- <br /> Address . r' – peddk=rl ~ <br /> Ci ty �..r' ,rrtj <br /> Contractor's Name License# Phone_ <br /> IS CERTIFICATE OF WORXMAt4-S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN Q RECONDITION ❑ DESTRUCTION❑ w <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION 22--- PUMP REPAIR d_ PUMP REPLACEMENT �] <br /> DISTANCE TO NEAREST: SEPTIC TAN `(,SEWER LINES/L4' PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI�� OTHER <br /> PROPERTY LINES RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE O �.WELL. CONSTRUCTION SPECIFICATIONS <br /> In ustrjal Cable Tool Dia, of Well Excavation <br /> Domestic/private Driljied; Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rota'ry Type of Grout <br /> Disposal OtheK� Other Information " <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor Llpi ' L, <br /> Type of Pump- XiL46 c H•P. � - ... <br /> PUMP REPLACEMENT: Q State Work Dore <br /> PUMP REPAIR: '- <br /> Q State Work Done l <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 ofthe work for which this permit is issued, I shall <br /> not employ any person in such manner' asto become subject to Workman's Compensation <br /> laws of California." <br /> I WILL CALL FOR A G OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: e DATE: 2 <br /> D L-T L N ON REVERSE SIDE <br /> PHASE I OR DEPARINEM USE ONLY . <br /> PPLI ATION ACCEPTEID BYy�.M DATE1,1e1717 <br /> ADDITIONAL COMMENT5,: <br /> PHASE STI GROUT INSPECTI <br /> INSPECTION BY QPHAS III 'FINAL INSPECT--14— <br /> DATE O INSPECTION BY DATE 12--1z�1 <br /> EH 14 26 Rev. 9/78 - 9/78 2M <br />