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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: . 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 001, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5-693. <br /> (tomplete -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. 715- os <br /> EXACT STREET ADDRESS CITY/TOWNIS, -&,, <br /> Owner's Name zi, Phoned <br /> Address city <br /> Contractor' s Name Li censer n c Phone n 16 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIM INS RANCE ON FILE WITH SJLHD? YES NO. <br /> TYPE OF WORK (Check) : NEW WELLUP DEEPEN 0 RECONDITION DESTRUCTION[D r-z� <br /> WELL CHLORINATION 0 WELL ABANDONMENT ED OTHER 0 V1 <br /> PUMP INSTALLATION Q PUMP REPAIR 0- PUMP .REPLACEMENT ❑ W <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES SO ' PIT PRIVY -- <br /> SEWAGE DISPOS FIELD —''._ CESSPOOL/SEEPAGE PI OTHER �--. <br /> PROPERTY LINPRIVATE DOMESTIC WELLY-92— PUBLIC .D MESTIC WEIU'- <br /> INTENDED USE TYPE OF WELL., CONSTRUCTIASPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �+ <br /> Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing <br /> -Irrigation =Gravel Pack Depth -of Grout Sea _ g <br /> Cathodic Protection Type of Grout . <rA4r <br /> Disposal Other Other Informat o�n �r<- <br /> Geophysical Surface 'Seal . Inst6l1ed , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H, . <br /> 'PUMP REPLACEMENT: ❑State Work Done s <br /> 'PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure r <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 WILL CALL FORA R T SECTION PRIOR TO GROUTING AND A FINAL INSPECTION. — + <br /> SIGNED TITLE: DATE:�Z3 <br /> DR W PLT L N ON REVERS SIDE <br /> FOR- DEPARTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYZ(L� DATE 2,ZI7,9 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III ' FINAL INSPECTr N <br /> INSPECTION BY DATE M ;=_ �; INSPECTION BY DATE 3Z 7 <br /> EH 14 26 Rev. 9/78 9/78 M <br />