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FFICE USE: SAN: JOAQUIN LOCAL HEALTH DISTRICT � <br /> 160IIE. Hazelton Ave. , Stockton, CA 95205 Permit No. t)-9 - 2/1 <br /> Telephone: ,(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date. Issued L -7 <br /> `tate , L6 T <br /> . (Eomplete;`In' 7'rip.i id"" �) :. � �Aa <br /> r <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 <br /> District, of the San JoaquinLoca] Health <br /> EXACT,STREET ADDRESS <br /> CITY/TOWN! <br /> Owner's Name <br /> ..� �..; Phone a3 ' --13 � . <br /> Address �' S"/ � - e . <br /> � . City <br /> Contractor's Name <br /> r a vert License#&2 ,-76/ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSAT ON INSURANCE ON FILE WITH-SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL El DEEPEN ❑ RECONDITION ❑ DESTRUCTION L, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP-REPAIR 0­ -RUMP REPLACEMENT [)-- <br /> 'DISTANCE TO NEAREST: SEPTIC -TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL.,FIELD CESSPOOL/SEEPAGEPTS— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC - DOMESTIG WEL �.. <br /> INTENDED USE TYPE OF..WELL.. � <br /> _ _ Industrials CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of We11 Excavation <br /> Domestic/private Drilled # O� <br /> ________Domesti c/publ i.c-.�...�..... s. - Dia. of Well Casing I <br /> _Irrigation -Dri-ven Gauge=-of Casing . ' <br /> Cathodic Protection <br /> Gravel -Pack Depth of Grout Sea <br /> ,Rotary Type of Grout <br /> isposal � Other Other Information <br />.Geophysical Surface Seal Installed by: <br /> PUMP. INSTALLATION: Contractor <br /> �. Type of Pump <br /> PUMP REPLACEMENT: - <br /> - [Mate Work Done `� ,�s �-r� <br /> PUMP REPAIR: <br /> i3St <br /> at– ,Work Done <br /> DESTRUCTION OF WELL., Well Diameter m r, <br />'� Describe Matel'Idl mand Procedure LL Approximate Depth <br /> Na <br /> I hereby certify that-Ihavepreparedthis application and that the work will be done in accordance <br /> with San Joaquin County Ord-ina�nces , State. Laws, -and-Rules and Regulations 'of the San Joaquin Local <br />'4ealt'h District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in'.the .performance of theLiwork for which this `pe' rmit is issued, I shall <br /> not employ any person in such <manrier as - <br /> 4to .become subject to Workman's Compensation <br /> laws of Californa. " - <br />[ WILD CALL�FOR-A �GROUT�INSP�CTION PRIOR TO GROUTING°"AND,� <br /> FINAL` JNSPECTION. _- <br /> �I G NED� _.. ;:..� .. <br /> TITLE _--- � �..�- DATE: 7 <br /> 119 <br /> R W P 0 L N ON REVERSE SIDE <br />'HASE I ' n FOR DEP RTMENT USE ONLY <br />,PP CATION ACCEPTED BY � <br />,DDITIONAL COMMENTS: DATE &` 7 <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY PHASE III FINAL INSPECTION <br /> 3 DATE <br />'1 14 26 Rev. 9/78 1 „� INSPECTION 8Y DATE – -7 <br />