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dor /b /0W > f'* SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ZZ,1,�#-F <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 /> Complete In Triplicate <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 /> 1'oaqui n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> riistrict. <br /> EXACT STREET ADDRESS <br /> 1'1901 21 . fes- <br /> CITY/TOWNT /t <br /> Owner' s Name T,*0ce2 .J �_r.w ,, �,,� � � - - - - - Phone <br /> Address---- -72) .r__J T City c. - <br /> Contractor's Name License# /f.;7;14--Phone <br /> IS CERTIFICATE OF WORKMAN'S C EN ATI0;1 I"1SURANCE ON FILE WITH SJLHD? YES X' NO <br /> TYPE OF WORK (Check) : NEW WELLED DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINAT.I,ON Q WELL ABANDONMENT ED OTHER 0 o <br /> PUMP�INST`A�LCATIOii PUMP REPAIR❑ PUMP REPLACEMENT 0 � <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 TYPE OF WELL 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 /> Irrigati.on Gravel Pack Depth of Grout Sea <br /> Cathodic Pr6tection Rotary Type of Grout <br /> Disposal, Other Other Information <br /> Geophysical Surface Seal Installed b,y____ <br />'PUMP INSTALLATION: Contractor ---jam <br /> Type of Pump __...._._._..__r�� .� ._ H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP R ❑State Work DoneZ / <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 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 /> laws of California. " <br /> I WILL CALL FOR A GROUT INSP TIO P TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ' ITLE: DATE: <br /> DR W P OT PL 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY {j DATE <br />,EH 14?6 Rev. 12-77. <br /> - -- 1 /78 2M <br />