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r SAN JOAQUIN•,LOCAL ;HEALTH DISTRICT <br /> 4� FF.ICE USE,: 1601 E. Hazelton Ave. , Stockton, CA 9.5205 Permit No. � <br /> Telephone:, (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP -PERMIT Date Issued <br /> This Peemit' Ex ices 1 Year From Date Issuedi <br /> Complete In Tri p i tate <br /> Application is hereby made to the San Joaquin Local Health District for a; permit .to construct <br /> acid/or install 'the-work here.in 'described.,. .. This application ,is made.-:in compliance with San <br />'. .'oaquin County Ordirnance No. 1862 and the �Rul-es_and. Regulations of the San Joaquin Local Health <br /> District. <br /> E1(ACT STREETADDRESS (JC✓ t "CITY/TOWN <br /> Owner's Name Phone/ <br /> Address,—. eL� City <br />-Contractor's Name (fes ` ,Licens4 Phone g <br /> IS CE------------------------ <br /> RTIFICATE OF WORKMAN'S COPiPENSATIO"!` I'ISURA^ICE 'ON FILE.-WITH SJLND? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] y y` <br /> R WELL CHLORINATION 0 WELL ABANDONMENT d OTHER 0 <br /> PUMP INSTALLATION ;A PUMP-'REPAIR 0,.,, 'PUMP REPLACEMENT Q <br /> .D1STANCE ,TO,,NEARE T: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> __J 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 / `1 y 'Drilled Dia, of Well Casing . <br /> Domestic/publis"� ' `�, , Dr.iveh '\ . Gauge of Casing <br /> IrrigationGravelPack '` Depth of Grout Seal �7 <br /> Cathodic ProtectionRotary - Type of Grout � <br /> Disposal , _ <br /> l Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br />.PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION, OF WELL: Well Diameter Approximate Depth ` <br /> Describe Material and Proce ure <br /> { <br /> I hereby certify that I have prepared this application .and that the work will be done in accordancEI <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. " 4 <br /> I WILL CALL FOR A, GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> D�RWPL T - L N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEP RTMENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY DATE -� >� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - _ INSPECTION BY _ DATE <br />_H 1426 ... Rew. -12--77 .� a � �f G z-�' <br />