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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F.F CE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: '(209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 -fora permit to construct <br /> and/or install the work herein described. This applications is ma-de-in- compliance with San <br />[ �oaquin County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN a 'F <br /> Owner' s Name 4_J%r; Phone <br /> Address - o ?— City <br /> Contractor' s Name- -.0 License# ( ""Phone '7: 7z <br /> IS CERTIFICATE OF WORKMAN'S 1PENSATION INSURANCE ON FILE WITH 'SJLHD? YES 'N0 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION[D <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR$0 PUMP REPLACEMENT <br /> f 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omesti c/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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP <br /> : <br /> PUMP INSTALLATION: Contractor tet. <br /> Type of Pump A , H•P• �— <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ®State Work Donee ��.. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 '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 INSPE ON P I-0R O GROUTING AND A FINAL INSPECTION. <br /> SIGNED. .: ITLE: DATE: <br /> RAWPLOPL N REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> 1 PHASE I <br /> APPLICATION ACCEPTED BY DATE °� 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE -II GROUT INSPECTION PHASE .111 FINAL INSPECTION <br /> , INSPECTION BY DATE INSPECTION BY DATE <br /> FFH 1,19r, 'p-1=11 19_77 1./78 2M <br />