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EFF�ICE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 - s a <br /> Telephone: (E09t66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �5--V_27 <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. s <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone U!?- ?6-5- <br /> AddressA 41c Ci ty� <br /> Contractor's Name License Phone_ <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION IN URANCE ON FILE WITH SJLHD? YE5 X NO- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION [� DESTRUCTION Cl. <br /> WELT. CHL R NATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION C] PUMP REPAIR O PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK,56 SEWER LINESSvI.{ PIT PRIVY <br /> SEWAGE DISPOSA FIELD► CESSP 0L/SEEP8GE PIT �--._. OTHER �— <br /> PROPERTY LINOL( PRIVATE DOMESTIC WELL TjDU- PUBLIC M ESTIC WE -� > <br /> INTENDED USE TYPE OF -WELL., CONSTRUCTION ool SPECIFICATIONS <br /> Industrial Cable TDia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing '�`�V, <br /> Domestic/public Driven Gauge of Casing e <br /> Irrigation =Gravel Pack Depth of Grout Sea <br /> Cathodic Protection _X Rotary Type of Grout <br /> —Disposal - Other Other Information <br /> —Geophysical Surface Seal Insta ed , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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. 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 -WI-L CALL FOR R T I CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED f <br /> TITLE: 44cldAj. DATE:�� <br /> D W <br /> 17T ?LKN ON REVERS SIDE <br /> PHASE I, DEP__ ENT USE ONLY <br /> TP—PLICATION ACCEPTED BY DATE ,5 � <br /> ADDITIONAL COMMENTS: <br /> PHAS . II GROUT INSPEUIUK PHASE 11I FINAL11LUSPECTION <br /> INSPECTION BY DATE__ 5L5 � ? INSPECTION BY E 7 <br /> EH 14 26 Rev. 9/ 8 9/78 1 ,244 <br />