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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> -!7 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6 z 'i <br /> (Eomplete' 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 .Rul,es and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS I3 60.4 So. / C CITY/TOWN A1&e .- <br /> Owner's Name Phone -g- -9 -.173rr <br /> Address Ci ty <br /> Contractor's Name Al*-6 License#g,(S:2v Phone <br /> XS CERTIFICATE OF WORKMAM'S COMPENSATION INSURANCE ON FILE WITH-SJLHO? YES ^ 0- <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION ❑ DESTRUCTION[] w <br /> WELL CHLORINATION 0 WELL ABANDONMENT [3 OTHER 0 � <br /> PUMP INSTALLATION x. PUMP REPAIR p- PUMP REPLACEMENTJV � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER .4 <br /> PROPERTY LINE - PRIVATE q0 ESTIC WELL PUBLIT—DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ---k—Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casin,i gIrrigation <br /> Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor 4-:& <br /> Type of Pump G It H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑State Work Done -` <br /> DESTRUCTION OF WELL: Well Diameter <br /> ApproximateDepthDescribe 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:' aqaAA DATE: <br /> D W PL T L ON REVERSE SIDE) <br /> PHASE I R DEPARTMENT USE ONLY <br /> PPS LICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _4z4__/ - <br /> PHASE II OUT INSPECTION PHASE-:.III ' FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7— <br /> EH 14� 26 Rev. 9/78 � 6 ✓ ' /78 M <br />