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Via . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Permit No. l- <br /> � FFICE USE: 1601 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date I ssued 7� 2-? <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to, construct. in <br /> and/or install the work herein described. ThandlRegulationsmofethe San pJoaquin wLocal ith aHealth <br /> -Joaquin County Ordinance No. 1862 and the Rules9 <br /> District. CITY/TOWN <br /> L EXACT: STREET ADDRESS �S S _ <br /> Phone <br /> Owner' s Name City <br /> AddressP= <br /> License# 3 L Phone <br /> Contractor' s Name , <br /> IS CERTIFICATE OF LdOfiK�iAil'S CO�i1'E ATI ,,I I"SSURAINCE. ON FILE WITH SJLHD? YES NO <br /> WORK (Check) <br /> 4 NEW WELL❑ DEEPEN E] RECONDITION C3DESTRUCTIONED <br /> TYPE OF rJWELL CHLORINATION WELL ABANDONMENT 0 OTHER ❑ , . <br /> PUMP INSTALLATION ❑ PUMP REPAIR M PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY pt, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ 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 /> t Drilled Dia. of Well Casing <br /> _Domestic/private Gauge of Casing <br /> C Domestic/public Driven <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 1 , 7 Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> E Surface Seal Installed b <br /> Geophysical. - <br /> PUMP INSTALLATION: Contractor a _ H,p, <br /> Type of Pump <br /> PUMP REPLACEMENT: [] State.Work Done , <br /> PIMP REPAIR: ®State Work Done L <br /> _. <br /> Approximate Depth <br /> DESTRUCTION OF WELL: , Well Diameter <br /> - � Describe Materia and Procedure <br /> ertif that I have prepared_ this application and that the work will be done in accord♦ <br /> S hereby c y <br /> with�San. .Joaquin- County Ordinances , State Laws , and Rules, 'and Regulati"ons 'of the San Joaquinol <br /> Health District. !some owner or licensed agent' s signature certifies the following: <br /> r w <br /> "1 certify that in the performance of the work fohich this permit is issued, I s'hali <br /> ubject,to Workman's Compensation <br /> not employ any person in such manner as to become .s .. <br /> laws of California ." ` <br /> I WILL CALL- FOR A GROUT INSPECT R •()R 0 GROUTING AND A FINAL INSPECTION. <br /> TLE: DATE: <br /> SIGNED W T PL ON REVERSE SIDE r <br /> FOR DEP RTME T USE ONLY <br /> PHASE I DATE <br /> WOLTCATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : PHASE I' FINAL INSPECTION <br /> PHASE 11 GROUT INSPECTION DATE/— <br /> NSQECTION BY DATE y ION <br /> r 6 = � 5/7 <br /> ;:u 14 ?E PPV- 9/78 <br />