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a� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 3.601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No. 9� <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued�S� .? <br /> (Eomplete In 'Triplicate} '' .. <br /> Application is hereby made the San Joaquin Lnca.1, Health District for a permit to construct.; <br /> and/or install thew described Th.�.s application is made �ln compliance with San <br /> Joaquin County 86 nd e, Rules...and Re ti s o t Joaquin Local'Health <br /> District. W s,f, , �� <br /> EXACT STREET ADDRESS 4 <br /> w 2 CITY/TOWN <br /> Owner's Nam' <br /> e ,ri Phone <br /> Address 70 <br /> ty x <br /> Contractor's Name /U� --• <br /> t License# 733 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE 'ON FILE WITr#' S.TLHD?.1" YES.: X � N0. <br />"�'YPE OF WORK(Check): W WELL 0 DEEPEN <br /> _DESTRUCTION 0W� <br /> WELL CHLORINATION EQ` WELL ABANDONMENT 0 OTHERV <br /> PUMP INSTALLATION.0 PUMP REPAIR[] PUMP REPLACEMENT_ � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY. '' <br /> SEWAGE DISPOSAL IELD CNES SP OL/SEEPAGE 'PIT" .OTHER <br /> PROPERTY LINE - PRIVATE DO ESTIC WELL .:..-PUBLIC D MESTIC EIEL <br /> --INTENDED USE <br /> . <br /> TYPE OFWELL.- .. ._... , <br /> Industrial GOIVSTRUCTION SPECIFICATIONS , <br /> Cable Tool Dia.- of We I :xcavation '�� <br /> Domestic/private <br /> Domestic/public —Drilled Dia, of Well Casing. m <br /> Irrigation Driven Gauge of. Casing <br /> Gravel Pack Depth of Grout Sea <br /> ______Cathodic Protection Rotary �` Type of Grout ., <br /> Disposal Other Other Information <br /> t Geophysical <br /> Surface Seal Insta ed "b : <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump H. <br /> PUMP REPLACEMENT: `State Work Done <br /> PUMP REPAIR: /��` ` <br /> ❑State Work Done ; <br /> pp oximatd <br /> DEt--e <br /> S2RUC7I: F WON—O .ELL: del-14-Di ameter�'y. A`. �-�_. •-� D� -t.�,d..�. <br /> Describe Materia an Prace ure ► p <br /> I hereby certify that ' I have prepared this application and, l <br /> vith 'San Joaquin County Ordinances , State Laws , and Rules andaRegulatt the �onswail.the SaneJoaquinin �Loeal� <br /> ieaTtt� 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 /> WILL CALL FORA- GROUT .INSP.ECTION PRIOR TO GROUTING AND-A -FINAL -INSPECTION. <br /> SIGNED. <br /> TITLE: DATE: <br /> DR W P L N ON REVERSE IDE <br /> RASE i <br /> F DEP RIME T SE ONLY F < f <br /> PPS ION ACCEPTED BY <br /> DDITIONAL COMMENTS: ;DATES Qj <br /> PHASE II GROUT INSPECTION - � <br /> VSPECTION BY PHASE III' FINAL .INSPECTION- <br /> DATE INSPECTION BY <br /> 4 14 26 Rev. 9/78 DATE=� x: <br /> —0 7 S� � 03 . 9/78 EM <br />