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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � FOR QFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 2_ '7 // <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ---27-2,9- <br /> (Complete <br /> --27-(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. 4 <br /> EXACT STREET ADDRESS f �LO� I� Cas-q tle,14 CITY/TOWN <br /> Owner' s Name o .C— r d 4 Phone <br /> Address City <br /> Contractor' s Name � , License# z Phone - 3 6'7-X'o <br /> IS CERTIFICATE OF WORKMIAN'S CO"SPENSATIOIN TNSURANCE ON FILE WITH SJLHD? YES _r NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT [@ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: [.]State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth /80 r <br /> Describe Material and Procedure A w <br /> 5-6 eeti49 <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. Nome 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 . " r" <br /> I WILL CALL FOR A UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �717� <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DE11ARTMEtV USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GRO?'T INSPECTION PHASE IIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATA _ r d <br /> Lei 14 26 Rev. - ,�_-_ 5z 4 7' CC-r� 5/79 2M <br /> 9/ --- - " o C, e <br />