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f .: SAN JOPUIN LOCAL HEALTH DISTRICT ` <br /> =FQRR )FFICt USE: 1 1601 E."4 Mon Ave, , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR,PUMP PERMIT, Date Issued(- <br /> (Complete In Tripl"ic <br /> ate).` <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 Regul'ationsxof the San Joaquin Local Health <br /> bistrict. <br /> EXACT STREET ADDRESS . S , CITY/TOWN cLtna <br /> Owner's Name e. L - L cz Phone" le y Z,.. . . <br /> Address . S . w City Q <br /> Contractor'.s NameL. License# Ir Phone �'3 79r <br /> ,IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES 0 <br /> TYPE 4F WORK (Check) : , NEW WELL[ DEEPEN ❑ 'RECONDITION ❑ DESTRUCTION[ <br /> WELL CHLORINATION Q. WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION .l PUMP REPAIRC3­ -- RUMP REPLACEMENT C] <br /> DISTANCE TO NEAREST: SEPTIC TAN Q1 5 O' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WE[[' -- <br /> INTENDED USt�'I TYPE OF.WELL., CONSTRUCTION SPECIFICATIONS <br /> .Industrial Cable Tool Dia. of Well Excavation��i��. <br /> � ,Domestic/private----- -- Dr�i7;1ed eli Ca.sin . -— - <br /> - �c� ubl i'C � Dri ..Oia..�.of,�.W g- :. ..,-•.�-.- —.: <br /> _D'bmes i p ven Gauge of Casing / �• <br /> Irrigation _Gravel Pack Depth of_Grout Seary' <br /> Cathodic -Protection �,( Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical r Surface Seal Insta e_d er <br /> PUMP INSTALLATION: xContractor <br /> Type of Pump 5 <br /> H.P. <br /> PUMP REPLACEMENT: State.Work'Done ..,....., <br /> ` 7 <br /> PUMP REPAIR: '❑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 he 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:Ig 11,42(IDRAW PLOT FEWN ON REVERSE SIUE <br />`PHASE I RDEPARTMENT LZE ONLY <br /> PP�"LICATION ACCEPTED BY DATE_ Ttlk,. 2 1977 <br /> ADDITIONAL COMMENTS: 7 1 _CJ <br /> P S i GROUT INSPECTION 7 PHASE II NAL.. INSPECTION <br /> INSPECTION 8Y DATE fOINSPECTION BY ATE <br /> EH 14 26 Rev. 9/78 9/7R 2M <br />