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{- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E, Hazelton Ave. , Stockton, CA 95205 Permit No-79 -�? <br /> Telephone: (209) 466-6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7-3-2 <br /> (Complete In Triplicate) <br /> x <br /> i Application is hereby made to the San Joaquin Local Health- Di'strict 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 /> t District. <br /> EXACT STREET, ADDRESS 3 �' . Gv e miz bee g CITY/TOWN SYdc -- <br /> Owner's Name Phone / <br />} Address 61 -5: C&Iqw Le City �5' bc� _. <br /> Contractor' s Name , ctr LicenseO,),-1 -Phone <br /> IS CERTIFICATE- OF 140PK"iAN'S ICO"iPENSATIO"f INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) :' NEW WELL DEEPEN C7 __. RE-CONDITION-Q DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT M OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR 0 PUMP REPLACEMENT � <br /> DISTANCE TO NEAREST: �'SEPTIC TANK f a� SEWER LINES�UGr PIT PRIVY <br /> k <br /> SEWAGE III FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r _ "-P.ROPI=RTY L`IN�E'']��RI.-VAT -DOMEST•IC_WE•LL-� .— PUBLIC DOMESTIC .WELL -� <br /> INTENDED USE 1,-,, TYPE OF WELL, „ CONSTRUCTIONSPE-C-IFIL TIONS <br /> Industrial -Cabl-e Tool, -Di.a.._of_ WellExcavation _ <br />` Domestic/private Drilled Dia. of Wel 1_Casing -� <br /> f Domestic/public- Driven--a ---. -Gauge of Casing <br /> Irrigation =Gravel Pack Depth of Grout Sea <br /> > Cathodic Protection Rotary Type of Grout P 0t <br /> Disposal. ether Other Information �-. <br /> Geophysical � ; Surface Seal Instal e <br /> PUMP INSTALLATION: Contractor: 4 .� <br /> Type of Pump X. H.P. <br /> i - Y <br /> PUMP REPLACEMENT: O.State Work= Done �--� -- - <br /> PUMP REPAIR: []State Work Done '�• <br /> DES�RUC� ' N-OF-WE'L1-: -TWel 1`-Diameter Approximate_.Depth <br /> Descr;i be Material and Procedure -k,• <br /> I hereby certify that I .have, prepared this application' and that the work will be done in accordan( <br /> with San Joaquin County Ord mantes , State Laws , and Rules and Regulations of the San Joaquin Loca' <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 /> E SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAR ON REVERSE SIDE <br /> F R D PAR MENT E ONL <br /> PHASE I <br /> APP'L rCATION ACCEPTED BY c DATE 19 <br /> ADDITIONAL COMMENTS : � <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DINE INSPECTION BY --- DATEff=19-7f <br /> r -H 14 26 Rev. 9/78 5/79 � 2M <br />