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SAN JOAQUIN LOCAL HEALTH .DISTRICT <br /> _ #FICE USE: 1601 E. Hazelton Ave. , Stockton, ,CA 95205 Permit No. <br /> Telephone: •(209) 466-6781- <br />" APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�5-3/-? <br /> (Complete In Triplicate), `' <br /> Application is hereby made to the San Joaquin Local Health -Distri.ct fora 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 /> o di Iver* <br /> EXACT STREET ADDRESS "O's k 'o. / o ,rea ZCITY/TOWN <br /> Owner's Name Phone - <br />: Address 4.0---- y cT✓ Cit _ . <br /> Contractor's Name R_ License# Phonez— ?d 7-6 <br /> E IS CERTIFICATE OF WORKMAN'S C01149FNATIQN INSURANCE ON FILE WITH SJLHD?' YES 0 <br /> k <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ® ' OTHER <br /> UMP=R <br /> PUMP INSTALLATION ❑ PEPAIR W1 PUMP REPLACEMENT C) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . ... ., ._ PIT .PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE FIT OTHER <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 _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domest c/,Public . Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> _ 'CathodicµProtection Rotary Type of Grout <br /> Disposal Other Other Information <br /> M .. Geophysical Surface�Sea1 Installed b <br /> BUMP INSTALLATION: Contractor -. � - — <br /> TYPe o��PumR — H. ��} <br />" PUMP REPLACEMENT: ' ❑State Work Done , <br /> PUMP REPAIR: [�]-State-Mork=Done'_,_ . -. ,� r ..Q <br />,,iE TRUCTIGN OF WELL: Well DiameterF Approximate Depth <br /> Descri'be -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 Ru les 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.11 <br /> I WILL CALL FOR A GROUT I CT RI TO GROUTING AND A-FINAL - <br /> SIGNE �k �ITLE:. acs _ - - M. DATE: ', <br /> LO L ON REVERSE SIDE <br /> OR DEPARTMENT U ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: -_ ,� DATEo{ <br /> PHASE=IT—GRQUJ SPECTION - <br /> INSPECTION BY PHASE - _.FINALME <br /> TION <br /> DATE INSPECTION B a 3 <br /> £H 14.__26 Rev. 9/78 �; V�` Q-7-7A- 7M <br />