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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 79- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued _3-..)4-7 <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. 35`f-S3"'"Sf[, r'ti -' $ . <br />,EXACT STREET ADDRESS to AJ 4 ZONE c Ck. jumaxe /TOWN <br /> Owner's Name & Phone - <br />'Address Ci ty� _+ <br /> 'Contractor's Name Licensek_Z�?Ifl/ Phone <br />- IS CERTIFICATE OF WORKMAN'S COIMPENSATIO" INSURAN E ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION [1, PUMP REPAIR❑ PUMP REPLACEMENT [3 <br /> DISTANCE TO NEAREST: SEPTIC TANKTQ�± . .SEWER LINES PIT PRIVY LA <br /> SEWAGE DISPOSAL, FIELD CE51L/SEEPAGE PIT — OTHER <br /> f ~PROPERTY LINF/Q-(PRIVA EDOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED-USE— y TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -Industrial Cable Tool <br /> Dia. of-We 1 Excavation <br /> Domestic/p�r�vate Drilled Dia. of Well'�Casing�1Is <br /> Domestic/.public Driven Gauge of Casing <br /> __X Irrigation Gravel Pack Depth of Grout Sea �--- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Ins ta ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />` PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MaterTa-1 an 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 /> 1 -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 /> IT WILL CALL FOR A G UT PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> tSIGNED TITLE: DATE: ,26 �0%a ' <br /> PLOT PLIN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> iPHASE I <br /> t PPPLIChTION ACCEPTED BY All DATE 3—,26 719 <br /> _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATES--�- ECTION BY C : TE � 11 /71 <br /> FH 14 2F Pau- q 17 R ko d-A . Avvn,,p KiPrttr, /7.8 2M <br />