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41 I� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P FFTCE. USE: 1b01 E. Hazelton Ave:-;Stockton, CA 95205 Permit No. <br /> i� Telephone: (209) 466-6781 <br /> APPLFICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This, Pe...rmi.t Expires 1 -Year From Date Issued <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 here:Tin described. This, application is made in compliance with San <br /> Joaquin County Ordinance No4 1862 and the' Rules- and Regu.lat'��ns of the an Joaquin Local Health <br /> Di strict. t �Z39 5.., 4PAi-'4 C._ GGc� '.. ��,J: Zr�•-oz�-o9 <br /> EXACT STREET ADDRESS -f' �. r��r l CITY/TOWN <br /> Owner's Name Pa ih Phone <br /> Address - �M City _}, _. _ I <br /> Contractor's Name Sc License# Phone_¢/� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! INSURAINCE ON FILE WITH SJLHD? YES 'il0 <br /> I <br /> TYPE OF WORK (Check) : NEWWELL DEEPEN 0 , RECONDITION ® DESTRUCTION[] <br /> ---------�------WE-L-L-�CHLOR-INAT � EL'L A <br /> I-ON-QW -BANDONMENT a- w—OTHER-0� <br /> PUMP INSTALLATION KF PUMP REPAIR❑ j .PUMP.�RERL-ACEMENT [J <br /> - ►, N <br /> DISTANCE TO NEAREST: SEPTfiC TANK /pf- SEWER LIP__S55,1 P•IT'PRI11Y, <br /> SEWAGE DISPOSAL, FIELD /Dp CESSPOOL/SEEPAGE .PIT i-, ..—OTHER--ti w <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL.-114' PUBLIC DOMESTIC:,WELL <br /> INTENDED USE I TYPE OF WELL o,! -CONSTRUCTION SPECI'FIGATIONS <br /> Industrial 1 Cable Tool Dia. oftiWell Excavation <br /> Domestic/private. I Drilled Dia. of .Well Casing { <br /> Domestic/public Driven ' Gauge ,of,Casing�___ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary. -Type of, Grout f <br /> Disposal `7""Other `Other`Inf*_matiori -� <br /> Geophysical : . }Surface Seal Installed by: <br /> PUMP INSTALLATION: ContractorType of Pump ; H.P. <br /> PUMP REPLACEMENT: 171 <br /> State Work Done <br /> PUMP REPAIR: ;estate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descr�l`ibe Material and Procedure <br /> I hereby certify that I have�. prepared this application and that the work will be done in accord nce <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local l <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 INSPjE TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Oil DATE: <br /> iM DRAW PLT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHAU,, III NAL INSPECTION <br /> INSPECTION BY BATE ��_�� INSPECTION bKj DATE <br /> f <br /> EH.1426__ Rev. 12-77 _a 1/78 2M 1 <br />