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F 7 <br /> SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No.7 9-,3- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From Date Issued <br /> Cpmplete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br />:I 'oao,,in County- Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health . <br /> tJiStr?Ct, <br /> t-EXACT STREET-ADD RES FS l J��6 L � �� CITY/TOWN /-a �"�►�►'c� <br />° Owner' s Name C7rr Phoneme <br /> l <br /> Address (� Z-Cl CityzC2.. <br /> Contractor' s Name S'-e License# Phone r <br /> F <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"J INSURANCE ON FILE WITH SJLHD? YES NO <br />' TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION,® 'DESTRUCTION[] � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION KT' PUMP REPAIR❑ PUMP REPLACEMENT ❑ <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 TYPEfOFiWELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 —z, Depth,,of)Grout_S.eal <br /> Cathodic Protection Rotary Type of`Graut <br /> Disposal Other Other I�formatfon-_i <br /> Geophysical Surface -Seal Installed b : <br />° PUMP INSTALLATION: Contractor 5e <br /> Type of Pump t - f H, . a <br /> - - -- <br /> PUMP REPLACEMENT: ❑ State World' Done .----- ----a--- <br /> PUMP REPAIR: Q State Work Done f_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mat6rial and Proce ure } <br /> 9 <br /> I hereby certify that I have preparedthis application and that the work will be done in accordance <br /> with San Joaquin County Ordinances, IState 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 t•he-°-performance of the work for which this permit is issued, I shall <br /> not employ any person�ln `such manner as to became subject to Workman' s Compensation f <br /> laws of California. " i + <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED -- - ,,,,_DATE: <br /> i <br /> 4 DR�W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT "USE:ONLY 5' �� <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTSPECTION PHASE-LIT-FINAL INSPECTION <br />'INSPECTION BY DATE INSPECTION BY DATE <br />'moi_-_1.4261 Rev_ _12-77 , - -_-___._ - <br /> 0?7 R ?Mks <br />