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. SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stbckton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION -FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - JK <br />"- �- This Permit Ex ires 1 Year From Date Issued <br /> Complete in Triplicate A. " <br /> Application 'is hereby made to ;the San Joaquin Local Health Di , c�fo 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 "ado. 1862 and the Rules and Regulations of the San Joaquin Loca.l .Health <br /> District. <br /> EXACT STREET ADDRESS �ii`f�`i Qc-,v CITY/TOWN <br /> Owner's_ Name ! ,L / stirs" Phone r <br /> Address /i s`4 iov -7 <br /> -ty...Sf� t-a <br /> Contractor' s Name /e 41 Art,4i /6'License# !(9,11_3 Phone 2 F= <br /> IS CERTIFICATE OF WORKfIAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO X 4 <br /> TYPE OF WORK (Check) : NEW WELD DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK (�V- tSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT70clr OTHER j <br /> PROPERTY LINE -. PRIVATE—DOMESTIC WELL L©' '` PUBLIC DOMESTIC WELL '� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /-2- <br /> < omestic/private __ Drilled Dia. of Well Casing 8 ' <br /> Domestic/public —Driven Gauge of Casing 4 <br /> Irrigation_,. m - -. Grave1- .Rack Depth-of- Grout- SeaI- Som <br /> Cathodic Protection Rotary Type of Grout. [jam <br /> __ _ _ r — tio6--- <br /> - <br /> W-- Di sposa�-- Others - " Other "Informa <br /> Geophysical �rLd vccd _ <br /> FSurfaceSeal° LI�ns;talled b : <br />� PUMP INSTALLATION: Contractor <br /> unSi x&/' <br /> :, <br /> Type of Pump mo yr 4 en ees 1',6 6C H.P. <br /> PUMP REPLACEMENT: F] State Work Done <br /> PUMP REPAIR: ❑State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t - <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- :arid Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s s-igriature certifies the following: <br /> "I certify that in the performance of the work fo►~. which this permit is issued, I shall <br /> not employ any person in such manner as• to,bec-ome' subject to Workman's Compensation <br /> laws of California. " <br /> + I WILL CALL FOR A GROU INSPEC ION PRIOR TO� GROUTING ANDA FINAL= INSPECTION. <br /> SIGNED TITLE: Lc -.� DATE: 6 <br /> DR W PL T PL N ON REVERSE..SIDE <br /> FORDEPAPJMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /4 //W- t,c�� DATE <br /> ADDITIONAL COMMENTS: S •�G -- ..,, t4- D 2 //- z ?3 <br /> PHASE II GROUT INSPECTION PHASE FI_"L INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> zy/��` .. <br /> __ 1 /78 2M - <br />