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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._2 9_ 0,1D <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedr�r/ -� <br /> (Complete in Triplicate) ..V •w..rc.,C1.--Z�8�6 <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 /> � —� <br /> EXACT STREET ADDRESS 951' <br /> CC1U0 A 7� CITY/TOWN Al TG — <br /> Owner's Name Phone <br /> Address S/ �t City ILI 7-&A-- <br /> Contractor's Name n.a6 A 9 AO Vof License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES O, <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION C$ PUMP REPAIR[3 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP-OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEL�� <br /> INTENDED USE TYPE OF-WELL.. CONSTRUCTION SPECIFICATIONS ""N <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge-of-Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instilled b <br /> PUMP INSTALLATION: Contractor (� <br /> Type of Pump - - H. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP A Q State Work Done <br /> ESTRUCTION OF WELL• Well Diameter (7 <br /> Approximate Depth <br /> Describe Material and Procedure -A <br /> t GO 2fl <br /> I hereby certify that I have prepared this application and that the work will be done in accordana <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 ALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: _3— 31`-79 <br /> DR W PL PL N ON REVERSE SIDE <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DAT E,7�37 <br /> ADDITIONAL COMMENTS: ---W <br /> PHASE II G OUT INSPEC ION PHASE III -FINAL INSPECTION <br /> INSPECTION BY ; <br /> INSPECTION BY_� DATE g s <br /> g1)�' <br /> EH 74 26 Rev. 9/78 r ., r-> C�9/7 2M <br />