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Cv� �a� o� SAN JOAQUIN LOCAL: HEALTH DISTRICT <br /> FFICE USE: vv 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 78 -/ I ?V <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ?-2S-?J <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_ g^�, ��,. h CITY/TOWN , <br /> Owner's Name AL- Phone <br /> Address .� "�} '� City_ <br /> Contractor' s Name- r.� �, Li cense#/4.4.2 ''Phone y <br /> IS CERTIFICATE OF WORKMAN'S CO" NSATION INSURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION[D <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION .5a PUMP REPAIR D 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— 4 A,e4l 4Arf H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP. ft-ERM4: ©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. " . . )�r <br /> I WILL CALL FOR A GROUT INSPECTIO PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED E: i^�.1' DATE: X <br /> W PLOT L N�N LREVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev.Re�s2-77" ____- - 1/78 2M <br />