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SAN JOAQUIN .LOCAL HEALTH DISTRICT Permit No. - b5a <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, CA 95205 <br /> Telephone: (209) 466-6781 Date Issued_f)-7-0-3q <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 /> Joaquin County Ordinance No. 1862 and the Rules and- Regulations of the San Joaquin Local Health # F <br /> District. <br /> EXACT STREET ADDRESS --Z- 4� j <br /> CITY/TOWN _ � t <br /> Owner's Name Phon <br /> ' <br /> C* <br /> Address <br /> "Li censer o Phon <br /> Contractor's Na e- Z J — -- <br /> COMPENSATION INSURANCE ON FILE WITH-SJu� <br /> IS CERTIFICATE OF WORKMAN'S C���rEN LHD? YES O, � <br /> TYPE OF WORK (Check) : NEW WELL[:] DEEPEN El RECONDITION [3 DESTRUCTION <br /> WELL CHLORINATION I-] WELL ABANDONMENT O. OTHERFJ <br /> 1 1 PUMP INSTALLATION ffl---fUMP REPAIR O PUMP REPLACEMENT O <br /> ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PST OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELD - <br /> INTENDED USE TYPE OF.WELL CONSTRUCTION SPECIFICATIONS <br /> In trial , Cable Tool Dia. of Well Excavation 71 <br /> f, omesti�/private _ __ Drilled Di.a-.-of, Wel] Casing <br /> Domestic/public Driven Gaugeof; -Casing <br /> Irrigation Gravel Pac-k _ ' Depth' of Grout g.Sea <br /> Cathodic Protection Rotary.. Type.-of-Grout Y - <br /> } Di,s-posal a —Other= Other Information <br /> Geophysical Surface S Insta ed byr: , <br /> PUMP INSTALLATION: Contractor- <br /> Type <br /> ontracto Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done s <br /> DESTRUCTION OF WELL: - r Well Diameter '-Approximate Deoth <br /> Describe Material and Procedure <br /> I hereby certify that I' have prepared this application and that the work will be done in accordar <br /> with San Joaquin Coun,ty,, Ordinances , State Laws ,. and Rules and Regulations of the San Joaquin Loca <br /> Health'-District'. Homeowner or licensed agent' s signature certifies the following: <br /> "I, cert �6 that in ,the performance of the work for which this permit is issued, I shall <br /> not em6loy any -person in such manner as to become subject to Workman's Compensation <br /> las of�C RIfornia." t <br /> I WILLCALL 1A GROUT INSPECTION R TO OUTING A FINAL INSPECTION. ; <br /> SIGNED TITL DATE: ,117 <br /> 7 <br /> r # R LAI" ON SIDE <br /> FOR DEPARTENT USE ONLY <br /> PHASE I <br /> 16, <br /> PPLIC,TION ACCEPTED BY DATE <br /> 'ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTIO PHASE III FINAL ' INSPECTION <br /> INSPECTION BY ,�/ DATE INSPECTION BY ,.r DATE Z- 2- 7-,7 <br /> EH 14 26 Rev. 9/78 9 <br />