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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: . 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No.-,7 9- 7;L <br /> U <br /> Telephoner (209) 466-6781 1 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PIMP PERMIT Date Issued G _d2 <br /> oin 1 ete I n <br /> (C. P Triplicate) <br /> Application is hereby made oto the San Joaquin Local Health' District' foi^ a' permit:to construct <br /> and/or install the work herein described. This application is made incompliance with San. <br /> Joaquin County Ordinance No.. 1862 and the Rules and Regd1ations' of'-thee San Joaquin Local Health <br /> District. a a <br /> EXACT STREET ADDRESS ' o CITY/TOW <br /> r, . <br /> Own`er's Name III iPhone <br /> ,Address 3?sr3 oca - -city � o <br /> lir -1 4 <br /> Contractor's Name tS License&JfEZg r Phone -90*f—� ' <br /> . ,IS CERTIFICPiTE OF WORK11AN S COMPENSATION INSURANCE ON FILE WITH•SJLHD? YES 0- I <br /> SY-PE�:OF_WORK (Check)—.:ANEW,—,WELL CI .DEEPEN 0 =toXCONDITI.ON <br /> WELL' CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 � '~ <br /> s . .PUMP INSTALLATION 21 PUMP REPAIR 0., PUMP REPLACEMENT L7 <br /> _ - R <br /> IDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMEST.ICiWELL PUBLIC D MESTIC WEL <br /> INTENDED -UgY,�, ��' JYPE OF.-.WELL., i F CONSTRUCTION SPECIFICATIONS <br /> � industrial Cable Tool Dia, of Well Excavation <br /> ;_Domestic/private E� Drilled Di•a. of Well Casing <br /> ,__� Domestic/publi.c Driven Gauge of Casing <br /> r <br /> ---:--irrigation Gravel Pack Depth of Grout Sea <br /> a _Cathodic Protection- '. Type of Grout <br /> _Disposal H - � Other <br /> Geophysical, � T' . i Other Information <br /> G <br /> ------- Surface Seal Installed b <br /> SUMP INSTALLATION. Contractor <br /> TYpe" of Pump H.P. <br /> PUMP REPLACEMENT: EI-State Work Done <br /> PUMP REPAIR: tState Work Done t <br /> DESTRUCTION OF_WELL: -'Wel 1. Diameter _ <br /> �- _ - '. r _ � � 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 accordam <br /> with- San Joaquin County-Ordinances , State Laws , and' Rules and Regulations_of the San Joaquin Loca� <br /> � Health`District. '_Home owner: or licensed agent's signature certifies the -following: <br /> k ,"I certify -that in the performance of the work for which this permit. is issued, I shall r <br /> not'employ any person in such manner as to become subject to Workman's Compensation <br /> Maws of California."- j F r <br /> � 1. WILL CALL FORA GROUT J NSP£CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ; SIGNED <br /> J. TITLE DATE: <br /> (DRAW -IL., PL N ON REVERSE IDE <br /> f <br /> FOR DEA RTMENTS ONLY <br /> PHASE I m <br /> E <br /> iVPPLICAtION ACCEPTED BY DATE <br /> AbDITIONAL COMMENTS: <br /> r' PHASE -:II =GROUT INSPECTION / PHASE II.T FINAL INSPECTION <br /> ,I,NSPECTION BY � DATE M INSPECTION BY DATE I� .7 <br /> !"EH' 14 26 Rev. 9/78 `� <br /> 0 - 9/?8, M <br />