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SAN JOAQUIN LOCA. HEALTH DISTRICT <br /> FF CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. a <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires. l 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 /> kloanuin County Ordinance No 1862 and the Rules and .Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS G ,i CITY/TOWN : <br /> Owner' s Name <br /> �i --S Phone <br /> Address City <br /> Contractor's Name &,42License# 7y Phone <br /> I5 CERTIFICATE OF WORKMAN'S COMPS ATI01J INSURANCE ON FILE WITH SJLHD? YES NO <br /> r <br /> TYPE OF WORK (Check) : 'NEW WELLL "DEEPEN CI �''RECONDITION�Q DES-TRUCTI"ONS -` <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT Q = ; <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 <br /> CONSTRUCTION SPECIFICATION5 <br /> Industrial : Cable Tool Dia. of Well Excavation , <br /> X 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 /> Disposals Other Other Information <br /> Geophysical Surface Seal Installed by: f <br /> PUMP INSTALLATION: Contractor . ff-e <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: We1,1.,Diameter ,. _ Approximate .Depth <br /> Describe Mater!7T and .Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> Nith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> lealth 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. " <br />[ WILL CALL- FOR A GROUT INSPECTI N PRI 0 GROUTING AND A FINAL INSPECTION. <br />;IGNED TITLE: DATE: <br /> if riR W PLOT PL N ON REVERSE SIDE <br />'RASE I _FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ,II GROUT. .INSPECTIO PHASE III FIML INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE 76 <br /> H1426 _Rev-_ 12-77 ,Ire <br />