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SAN ;OAWtN LOCAL HEALTH DISTRICT -----� <br /> fOR F CE USE: 1601 E! �I ielton Ave. , Stockton, CA 95205 Permit No.79—f,217( S <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,;?-�.4-7,9- <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 12--33 CITY/Teft"-5; !/4?%'� <br /> Owner's Name r << //'A <br /> Phone <br /> Address V City . <br /> Contractor's Name M 007" /?s y ; License Phone <br /> JS CERTIFICATE OF WORKMAN'S CO";PENSATInM iN RANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0--" DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ iWELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION fK PUMP REPAIR❑ PUMP REPLACEMENT Ca <br /> DISTANCE TO NEAREST: SEPTIC TAMC EWER LINES 11-PIT PRIVY <br /> SEWAGE DISP S E.IELD CESSPOOL/SEEPAGE � <br /> PIT- Q/`OTHER ---"_ <br /> PROPERTY LIN PRIVATE D MESTIC WELL PUBLCDOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We 1 Excavation / 1�wle-1 <br /> � iDomestic/private vBFi11ed Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing e- <br /> Irrigation Gravel Pack Depth of Grout ea <br /> Cathodic Protection rotary Type of GroutT_ �4 i-- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor km rw <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <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: DATE: <br /> ON REVERXE SI <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> A PLI ATION ACCEPTED BY DATE 911`f1`7 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY - DATE INSPECTION BY r/)!1 DATE <br /> EH 14 26 Rev. 9/78 9 2M <br />