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s <br /> [ ASAN JOAQUIN LOCAL }HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> Date Issued -// -`7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (tiomplete In Triplicate) .. .� <br /> ri - it <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�comp'liance with San <br /> , Joaquin County Ordinance No. 1862 and the Rules and .Regulations of the San :Joaquin Local Health <br /> District. J <br /> EXACT STREET ADDRESS ,SQS IV CITY%TOWN�,r.� <br /> Owner's Name Phone - <br /> t Address Ci ty. . <br /> Contractor's Name License / Phone - „ezio . _ <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURA"• E ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK -(Check) :-'-NEW WELL DEEPEN`Q. -RECONDITION DESTRUCTION[ <br /> 'WELL. CHLORINATION E3 WELCABANDONMENT 0 OTHER 0 - <br /> "PUMP' INSTALLATION E7 PUMP REPAIR❑ PUMP REPLACEMENT C1" ' <br /> DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES�SS , /, �. ..PIT PRIVY µ <br /> SEWAGE DISPOSAL FIELD CE5SPOOL/SEEP�IGE PIT — .OTHER <br /> PROPERTY LINV44 PRIVAE0ESTIC WELD-�-- PUBLIC DOMESTIC W��-- = <br /> i ; INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Di'a. of Well Casing " <br /> Domestic/publ tc:j, ,Driven Gauge of Casing <br /> Irrigation Graver Pack Depth of Grout Sea ' <br /> ., Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> .. Geophysical S'urface"Sea1- Ihsta ed b : <br /> PUMP INSTALLATION: -Contractor <br /> Type of Pump H.P. <br /> : PUMP 'REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> FDESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material ana Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordam <br /> with San Joaquin County Ordinances-,, State Law"s ,.. 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 /> lawn of California. <br /> ,I WILL CALL FOR A.,O.�QJAT I P CTION PRIOR TO GROUTING AND A'FINAL INSPECTION. s , <br /> SIGNED' TITLE: - DATE: Jjoy <br /> PLOT PEWON REVERSE DE <br /> FOR DEPTRTMENT USE ONLY <br /> PHASE .I <br /> APPLICATION ACCEPTED BY DATE �Ju_X - 7% <br /> AbOITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE Z. INSPECTION BY �L �� DATE r <br /> EH 14 26 Rev. 9/78 --`l sem' _ �, _, 9/ 8 2M <br />