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SAN JOAQUI.N LOCAL HEAL'IH UISIRICI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. � — J� <br /> Telephone: (209). 466.-6781 <br /> Date Issued]! �, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> (.Complete In Trip 'icate ; <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 'a.nd .Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS I CITY/TOWN� �� <br /> Owner's Name Cz Phone R,?jr- � <br /> Addressf� <br /> C i ty s <br /> Contractor' s dame License Phone <br /> IS -CERTIFICATE OF WORKHAN'S -COMPENSATIO,! -INS-URANCE ON—FILE-WITH SJLHD? -YES NO <br /> TYPE OF WORK (Check) : NEW WELL E DEEPEN [3' "-�- R'ECONDITION�'-o � . *DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER p <br /> PUMP INSTALLATION Ca PUMP REPAIR 0 - PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK,504 SEWER1LI-NESPIT, PRIVY <br /> SEWAGE DISPOS L FIELD CESSPOOL/SEEPP,GE PIT _OTHER <br /> PROPERTY LIN ! DOM <br /> PRIVATE ESTIC WELL-C?—'� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF.,.kLC" :. "_'CONSTRUCTI-ON SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well�Excavation ZI <br /> Domestic/private Drilled Dia. of Well Casing. <br /> Domes tic/public _ u �' Driven ... :. �.- ..Gauge-of Casing "' ` <br /> ' Irrigation Gravel Pack Depth of Grout. SeaT s <br /> Cathodic Protection Rotary Y Type of Grout C _ <br /> Disposal Other Other Information <br /> Geophysical Surface_Seal_ Instal ed_b__L <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. t <br /> PUMP REPLACEMENT: []State Work Done =- i <br /> PUMP REPAIR: Q State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Describe Material ana Procedure <br /> I hereby certify that I have prepared this application and that the work wiJl 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: 1. <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 /> I WILL CALL, FOR A GROUT INS C N OR TO IIOUTI-NG AND A FINAL INSPECTION. <br /> SIGNE TITLE: _ DATE: ' ' <br /> D W PLT PLAN ON REVERS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE " <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAj INSPECTION <br /> INSPECTION BY -DATE INSPECTION BY TE 4 <br /> ;" f 67 <br /> c. <br />�H 1426 Rev. -12-77 _ 1178 2M <br />