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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EQR OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 79 - 6,5L <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued 3/-7 g <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 <br /> District. <br /> EXACT STREET ADDRESS 119-7 -7 N 14 t CITY/TOWN <br /> Owner's Name - <br /> g_,, Phone 3 <br /> Address f <br /> � � � City_ <br /> Contractor's Name Cc,r, cs L .f S,5 r License <a Phone `7Y-�T;,/ 3 Y "7 <br /> IS CERTIFICATE OF WORK"SAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES- 4--'- NO <br /> TYPE OF WORK (Check) : NEW WELL tk��DEEPEN Q RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR 0- - POMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK?6_ SEWER LINES 16-6 PIT PRIVY <br /> SEWAGE DISPOSAL--FIELD CESSPOOL/SEEPAGEPI�� OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D-FMESTIC WELL <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Industrial A_—Cable Tool Dia, of 'Well Excavation <br /> y_Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge- of Casing C� <br /> Irrigation Gravel Pack Depth of Grout Sea 6 <br /> Cathodic Protection Rotary Type of Grout < <br /> - Disposal Other Other Information " <br /> _ Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of- Pump k H. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: QState Work Donee <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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: dz> DATE: <br /> (DRAW PLOT PLANON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PPSLICATION ACCEPTED BY DATE d 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE hr -�� INSPECTION BY �� DATE �- <br /> EH 14 26 Rev. 9/78 `'"" <br /> -- - - --- - - 9J.78 2M <br />