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Ga•�. La.� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1 16011. Hazelton :Ave-: , Stockton, CA 95205 EDate <br /> t No. -7 <br /> i, Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued <br /> This Permit Ex ices 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' ih'stall' the work herein described. This.application is made in compliance with San <br /> Joaquin C6unty` Ordinan8e No. 1862 and the- Rules and -Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREE _ _ <br /> T ADDRESS 5'7od.t AP —F" � S tam - CITY/TOWN <br /> Owner's Name i m V clx-AL,��,�," Phone <br /> AddressT ado/ f�/.. � �( City <br /> l Contractor's Name �1. License# A j-"Phone y 6 7 Z <br /> I5 CERTIFICATE OF WORKMAN'S COIMP A °101-1 INSUOVICE ON FILE WITH SJLHD? YES ! NO <br /> ` TYPE OF WORK (Check) : NEW WELL 0 DEEPEN [] RECONDITION DESTRUCTION C4 <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 10 PUMP REPAIR❑ PUMP REPLACEMENT [ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER s <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well -Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel- Pack ` Depth of Grout Seal <br /> I Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMENT: F9 State Work Done R4e <br /> . PUMP REPAIR: 1 ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material ana Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Homel�'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 M <br /> not employ any person fn such manner as to become subject to Workman's Compensation <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSPECTIO R OR:T GROUTING AND A FINAL INSPECTION. <br /> 4 <br /> SIGNED _ LE: DATE: s <br /> �PMW PEOT PL ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> f APPLICATION ACCEPTED BY DATE j 2b <br /> ADDITIONAL COMMENTS: 11 <br /> I PHASE II GROUT INSPECTION PHAU- III FINAL INSPECTION <br /> INSPECTION BY 11 <br /> DAT£ INSPECTION BY ;4 <br /> ,�-.-- DATE 3� �, <br /> #Fp t a9r RAi, 19-77 N , _ 1 .,. 1/78 2N_ <br />