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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Haielton Ave. , Stockton, CA 95205 Permit No. �- 614 <br /> Telephone: (209) 466-6781 <br />` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _Zi _ <br /> (complete in Triplicate-). <br /> Application is hereby made to the San Joaquin Local Health District- far a permit to construct <br /> and/or- install the work herein described. This`application is made in compliance with Sant <br /> Joaquin County Ordinance No. .1862 and the Rules and Regulati,onsr.of the San ,Joaquin Local Health <br /> f <br /> 'District. <br /> `EXACT`STREET ADDRESS 11393 CITY/TOWN <br /> -Owner's Name arm <br /> Ph6ne <br /> Address & 10 k]. Ci.ty . <br /> Contractor's Name -t c License# /93 Phone j�(ak� <br /> IS CERTIFICATE -OF WORK��A�J'S CO"",PE TION INSURANCE ON FILE WITH SJLHD? YES NO <br /> s TYPE OF WORK (Check) : NEW WELL 0 DEEPEN El "' -RECONDITION [3 DESTRUCTION d <br /> WELL CHLORINATION D WELL ABANDONMENT 0 OTHER 0 - <br /> PUMP INSTALLATION 0 PUMP REPAIR C@ PUMP REPLACEMENT CD <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES :.. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS,PooL/SEEPAGE PIT ..OTHER <br /> PROPERTY LINE - PRIVATE-DOMESTIC WELL PUBLICDUMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of WeT1 Excavation <br /> i Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> i _ x .Irrigation ° Gravel Pack Depth of Grout Sea <br /> _ Cathod-ic Protection Rotary Type .of Grout <br /> Disposal Other �urfaceInformation <br /> lnsta e <br /> Geophysical <br /> PUMP INSTALLATION: ' ' Contractor <br /> Type of Pump H.P. v <br /> PUMP REPLACEMENT: Q State Work ,bone R • -} -- - �" ` <br /> ' PUMP REPAIR: State Work Done <br /> DESTRUCTION OFa,.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 .accordanc <br /> , with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the_ San .Joaquin -1ocal <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 INS . T N I TO GROUTING' AND A FINAL INSPECTION: <br /> SIGNED ITLE: DATE: Co <br /> A,A L <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FORDEPATMENTZSE ONLY <br /> ; PHASE I <br /> :APPLICATION ACCEPTED BY /LcoO DATE <br /> FADDITIONAL COMMENTS: <br /> PH SE JI GROUT INSPECTION PHASE III FINAL INSPECT ON <br /> [INSPECTION SY DATE INSPECTION BY DAT 9 <br /> EH 14 26 Rev. 9/78 9 78 <br /> �2M <br />