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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1l ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 -9- 740. <br /> Telephone: (209). 466-678;1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7- 9 7 <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 /> ,'eanuin County Ordinance No . 1862 and the Rules and Regulations of the San Joaquin Local .Health � <br /> Distr�cj- <br /> EXACT STREET ADDRESS e CITY/TOWN <br /> Owner'.s"- Name r Phone <br /> Address t City <br /> Contractor' s NameLicense - :^Phone <br /> IS CERTIFICATE OF WORKMAN IS C,OMPENSATIO'N INSUR-AtlCE°=Otl--F-I-LE-WITI1 -SJLHD? YES:J-- x' N0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN O RECONDITION DESTRUCTION M <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q---OTHER 0 <br /> PUMP INSTALLATION QU PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK Lej& ER LINES S-0 PIT PRIVY <br /> SEWAGE DISPOSAL F ELD CESSPOOL/SEEPAGE PIT _OTHER'--' <br /> PROPERTY LIN , PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.R".of=Well Excavation s <br />' y Domestic/private Drilled Dia. of Well Casing :- <br /> Domestic/public Driven w Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seai <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor �L-%r+ <br /> Type of Pump H.P:' <br /> �f r <br /> PUMP REPLACEMENT: []State Work Done <br />' PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well DiameterApproximateXDeptlh <br /> Describe Material an2 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 thi.s�permit is issued,' I shall <br /> not employ any person in such manner as to becoinefs,ubject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRUIR TO GROUTING AND--A-FINAL INSPECTION. <br /> SIGNED TITLE: - DATE: ' <br /> IV,17- <br /> _ . �DRAW PLOT PLN ON REVERSE. SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE.-ONLY-1. <br /> APPLICATION ACCEPTED BY ,1,Q ex-o DATE` J7 if 7 <br /> ADDITIONAL COMMENTS : <br /> __ PHASE. II _GROUT...INSPECTIO - - - r -PHASE-III F-I NAL INSPECTION <br /> INSPECTION BY_� DATE. ..,. INSPECTIO[V BY '� ;. ... DATE. �-O , <br /> 4EH 1426 RaU- 19-77 M 1 /78 2M <br />