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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave, , Stockton, CA 95206 Permit No. 7,9_'70 <br /> Telephone: (209) .466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued G- 1 -7 <br /> (fi:omplete 'In Triplicate)` <br /> Application is hereby made to the San Joaquin Local Health District for a permit toeconstr'uct <br /> ,and/or install the work herein described. This application is ma-de-in compliance with San, <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations. of the San Joaquin. Loca1 Health <br /> District. <br /> EXACT STREET ADDRESS <br /> N I TY/TOWN <br /> Owner's Name / SPhone_ �7- C9'afz': <br /> Address <br /> Ci <br /> Contractor's Name z-' <br /> License Phone <br /> IS CERTIFICATE -OF--WORKt1AN'.S' COMPENSATIOrI, INSURANCE ON FILE WITH SJLHD? YES _ 0 <br /> 1, _yECOF WORK (Ch`e'ck) : '- .NEW WELL— - DEEPEN'- =-RECONDITION DESTRUCTION[ -" '57 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATIONEl PUMP REPAIR❑ PUMP REPLACEMENT`Q i <br /> S <br /> DISTANCE TO NEAREST: SEPTIC TANK!5',Q4 SEWER LINES _-0,, PIT PRIVY <br /> SEWAGE ,DISPOS L OL/SEEPAGE PITT OTHER'--- , <br /> PROPERTY LINO� �� <br /> TEED CESSP O <br /> +PRIVATE DOMESTIC WELL�—�PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />____Industrial Cable Tool Dia. of Well Excavation <br /> D omestic/private Drilled Dia. of Well Casin <br /> Domestic/public Driven Gauge of Casing pTr <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> eophysical Surface Seal insta ed b : ---� C_ -� <br /> PUMP INSTALLATION:,,, Contractor <br /> Type of Pump 3 <br /> H.P. <br /> PUMP REPLACEMENT: ']State Work Done Yi <br />'UMP REPAIRi Q State Work Done <br /> IESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I- have prepared this application and, that the work will be done in accordance. <br /> Fith San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Local <br /> Iealth 'District. Home owner or-licensed agent's signature certifies the following: l <br /> "I'certify .that in. the' performance of the work for which this permit is issued, I shall <br /> knot employ any person in such.manner as to become subject to- Workman's Compensation <br /> laws of California. <br /> WILL CALL FOR..A G UT NSP fC ON PRIOR TO GROUTING AND A FINAL INSPECTION. .. <br /> IGNED , <br /> TITLE: tir DATE:�f ,� <br /> JY <br /> PL _?_LWON REVERS SI E <br /> FIASE I FOR D.EP R1MEN USE ONLY x <br /> PP�LICATION ACCEPTED BY - - V . .�+� DATE g��XA5�DDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTION <br /> JSPECTION BY PHA E I INAL INSPECTION } <br /> DATE INSPECTION.BYDATE 2819M <br /> 1 14 26 Rev. 9/78 - <br />