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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, CA 95205 Permit No. -29- _2.2L <br /> Telephone; ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - - 7 <br /> (t:omplete In Triplicate} r <br /> 2 - <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 Vthn Rules and Regulations of the San Joaquin Local Health } <br /> District. { <br /> EXACT STREET ADDRESS,44 A,1 . ,,- Ar s r,;:,',1: aA/TOWN &e,4-41A <br /> Owner's Name 1� � ' r./ € _ Phone: ,'.: y�;1 f. <br /> Address Alk" _ Ci ty ?, � . <br /> Contractor's Name#. . r �t, �. .. License#'O.�' .'/ l Phone c"/`� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES V, 0 <br /> TYPE OF WORK (Check) : NEW WELLM DEEPEN Q RECONDITION DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER FJ -_ W <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK-/, '! SEWER LINES _," + PIT PRIVY • <br /> SEWAGE DISPOSAL FIELD,,,, _� CESSPOOL/SEEPAGE PIT -_ OTHER <br /> PROPERTY LINE== PRIVATE DOMESTIC WELL.`, ' '. PUBLIC DOMESTIC .WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial—_ Y Cable Tool Dia, of Well Excavation ,,,3 ` <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing *{� . <br /> _ X_I rri gati on Gravel Pack Depth of Grout Sear i <br /> Cathodic Protection. Rotary Type of Grout <br /> Disposal Other Other Information ��--w <br /> Geophysical Surface Seal Installed by: <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: [I State Work Done <br /> PUMP REPAIR• <br /> ❑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 FORA GROUTKINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />{SIGNED TITLE: ,i DAT E <br /> D ON REVERSE SI E <br /> FOR DEP RTMENT USE UNCY <br /> PHASE I <br /> ` 3--16- <br /> _��r 7 <br /> PLICATION ACCEPTED BY �- /,c1 DATE T <br /> !ADDITIONAL COMMENTS : - <br /> PHASE . II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 9/78 2M <br />