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r FFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 2601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 9- 7/ � <br /> I Telephone: (209) 466-6782 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (,Complete In Triplicate) <br /> :Z'ff-3 2e -ss <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! 2862 and the Rules and- Regulations of <br /> District. the San Joaquin LocalHealth <br /> EXACT STREET ADDRESSIX <br /> fW CITY/TOWN <br /> Owner's Name <br /> Address Phoneme <br /> Contractor's Name C1 ty ,,.1., <br /> - �� '" License Phone G <br /> 15 CERTIFICATE OF WORKMAtN'SCOEiPENSA7I0N INSURA"NCE ON FILE WITH-SJLHD? YES <br /> TYPE OF WORK-(Check) : NEW WELL 0 DEEPEN ❑ RECONDITION <br /> WELL 'CHLORINATION D WELL ABANDONMENT Q DEOTHER 0 �� <br /> PUMP INSTALLATION 0 PUMP REPAIR[3 RUMP REPLACEMENT �--- <br /> DISTANCE TO NEAREST: SEPTIC TANK Ajv--'--. SEWER LINES PIT PRIVY <br /> SEWAGE DISP SSA FIELD CESSPOOL/SEEPAGE -P-17— OTHER <br /> PROPERTY LINEdPRIVATE DO ESTIC WELL PUBLIC DOMESTIC WE L <br /> INTENDED USE TYPE OF.WELL... CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Wei Excavation <br /> Domestic/private -__Drilled Dia, of Well Casing <br /> ,--- Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> -----__Cathodic Protection Gravel Pack Depth of Grout Sea Disposal Rotary Type of Grout <br /> —,Geophysical. Other Other InformatFTon ; <br /> Surface S.Lan ed b <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump <br /> PUMP REPLACEMENT: i <br /> ; r <br /> State Work Done ,�,<<` <br /> PUMP REPAIR: ❑State Work Done "54 7b_ 'S ` <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia and Proce ure Approximateepth <br /> I hereby certify that I haveIirepared t <br /> wihis application and that the work will be done in ac <br /> th 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 /> ` "I certify that in the performance of the work for which this pe <br /> ri�it. is issued, I shall <br /> not employ airy person in such manner as to become subject to Workman'-s Compensation <br /> laws of California. <br /> I WILL CALL -FORTA-GROUT--I:NSP'ECTTOIV"P1tT0>� �IGROUTING AND FINAL ,INSPECTION, <br /> SIGNED - _.. _ .r.w _ r „a <br /> TITLE: t- `DATE: 2.7. <br /> -� D W PL -_.. ON R ERSE,SIDE <br /> N. R DEP RTME USE4ONLY <br /> PHASE 'I - _ <br /> APPS ION ACCEPTED BY -wl <br /> ADDITIONAL. COMMENTSf " _ DATE I? 7 <br /> PHASE ISI GROUT .INSPECTIONI <br /> INSPECTION BYN DATE PHASE III FINAL INSRECTTON <br />:'H 14 26 Rev. 9/78 INSPECTION BY DATE 7-G �9 <br /> 9/7A M <br />