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SAN JOAQUIN-.LOGAI. HEALTH DISTRICT <br /> - <br /> W1 USE: 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit No. 714 <br /> Telephone:' (209) 466-6781 " <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued !� <br /> This Permi.t .Ex ires 1 Year From Date Issued <br /> Complete In Triplicate <br /> kApplication . 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 /> LloaQuin County Ordinance No. 1862 and. the Rules and Regulations' ' <br /> ..of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESSF CITY/TOWN',s'/oc _ <br /> Owner' s Name_&Lf'i✓� Phone <br /> ' Address f 3-- �- �/L> � �f�-� ---- Ci tY. 15'kcTrs :. <br /> Contractor's. Name License#2��'- Phone�L <br /> IS CERTIFICATE OF WORKMAN`S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES Zf-� NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION(D -- <br /> f WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER { � <br /> i PUMP INSTALLATION 93— PUMP REPAIR[] PUMP REPLACEMENT Q <br /> ` DISTANCE .TO NEAREST: SEPTIC TANK/fj' SEWER LINES�(� PIT PRIVY <br /> SEWAGE DISP SAL <br /> �FiELD /c+ " CESSPOOL/SE£PI�E PIT OTHER _ <br /> PROPERTY LINVVV PRIVATE DOMESTIC WELL .4�D PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .4 ndustrial Cable Tool . Dia, of Well Excavation C> <br /> 'Domestic/private Drilled Dia. of Well Casing <br /> ! Domestic/public Driven Gauge of Casing <br /> ,tlrrigation }.,. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical `' Surface Seal Insta1,led b <br /> -PUMP INSTALLATION: Co tractor <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 <br /> Describe Materia an Proce ure <br /> F <br /> PI 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 /> lHealth District. Home owner or licensed agent' s signature Fcertifies the following: <br /> "I certify that in the .performance"'f 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 INSPECTION PRIOR,-TO GROUTING ANDA FINAL INSPECTION. <br /> , SIGNEDTITL ' e <br /> DATE:T <br /> �--�- �- DR PL T PL N ON REVERSE SIDEDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I -,�- --- <br /> 'APPLICATION ACCEPTED BY 1 DAT E-/7-7 p <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION -PHASE III FINAL INSPECTION-, <br /> INSPECTION BY DATE INSPECTION BY DATE.. <br /> L H„1426 Rev.. 12-77 - 1 178 2M <br />