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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , ,Stockton, CA 95205 Permit No.Zg_/6 ?3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,/d-,�/�.-7R' <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 L 0' CITY/TOWN 'Vrr1 <br /> Owner's Name ma �o g Phone 725--o-4i <br /> Address r Cityr s <br /> Contractor' s Nameg. '� License# Phone <br /> IS CERTIFICATE OF WORKIIAN'S COMPENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL I1 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATIONW WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ N- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> Domestic/private _Drilled Dia. of Well Casing r+ <br /> Domestic/public Driven Gauge of Casing e_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor 11 i <br /> Type of Pump--Zr,_t H.P. J <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: ❑State 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 WOUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: AZ7tV7� <br /> DR W PLOT PLAN ON REVERSE SI <br /> FOR DEP RTMENT—U,E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATk---, - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL NSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br />_Fly 1A9F pinto 19_77_ LoT 37 W1 /7R' 2M , <br />