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5FFICE <br /> SAN JOAQUIN LOCAL HEALTH DISfRiCT <br /> USE: v 1601 E. Hazelton Ave. ,, Stockton, CA 95205 Permit No.Tg,-/W4/ <br /> Telephone: . ' -('209)-4'66-6781 <br />—= APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/,p -4-7,T <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. <br /> EXACT STREET ADDRESS a Ys CITY/TOWN C=�,O/o-�� <br /> Owner's Name -Sala ' Phone <br /> Address 47- )�-4. City <br /> Contractor's Name n /- ter, License# /y57-,-.y--none ' <br /> IS CERTIFICATE OF WORKMAN'S COtZ NSATIO"! INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPE� ❑ RECONDITION [3 DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION Q. PUMP REPAIR(.9) PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER F <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 i <br /> _Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public . Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump . a -p-ir,d H.P. s <br /> PUMP'. REPLACEMENT: 71 State Work Done f <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 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 GROUT IN CT ON R TO GROUTING AND A FINAL INSPECTION. <br /> S I G N E ' ITLE: DATE: 1 d ;,- <br /> DR PLOT PtAff ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY- �Zj: A . DATE cl -Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE JAI FINAL INSPECTION k <br /> INSPECTION BY DATE INSPECTION B ° DATE <br /> � k <br />:H 1426 Rev. 12-77 7•'"1178 2M <br />