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/ SAN JOAQUIN LOCAL HEALTH DISTKICi <br /> QR OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 T <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �,_ ,7 88' <br /> This Permit 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 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 /> District. q <br /> EXACT STREET ADDRESS_ /30 J CITY/TOWN <br /> Owner's Name Phonef r--,IV7-_ ea0 <br /> Address—! Cit f,Contractor's Name Li cense#oV6o, , Phone <br /> IS CERTIFICATE OF WORKMAN'S CO'iPENSATIO"! T'NSURAINCE ON FILE WITH SJLHD? YES --- N0 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION Q DESTRUCTION[D <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION, PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN£ -, 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 7777Ailled Dia. of Well Casing \t <br /> Domestic/public , ven Gauge of Casing <br /> Irrigation vel Pack Depth of Grout Seal <br /> Cathodic Protection V Rotary ' Type of Grout " <br /> Disposal Other .. Other Information <br /> Geophysical Surface Seal Instal d by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION 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 accordance <br /> with 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 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 GRQK INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY__ _ _S, DATE 4- 71 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INVECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATEfd- CZE- 76 <br />-E1-142.6 Rev_ 12-77 __ 1118 2M <br />