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MFFICE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.! - 3 7 ,i <br /> Telephone: (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT - <br /> Date :.Issued - �2 <br /> ; (complete-I.n "Tri-plicate) <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 •wfth 'San <br /> Joaquin -County -Ordinance No. 1862 and the �Rules and- Regulations of the San Joaquin Local -Heal'th <br /> Di strict. <br /> EXACT STREET ADDRESS CD _ - ` CITY TOWN <br /> - / , <br /> Owner's -NamePhone -4/ <br /> Addres <br /> t. Ci ty� <br /> Contractor's Nam <br /> - cre License#� z Phone `7 —.3 VC1, <br /> IS CERTIFICATE "OF tJORKMAN'S 6MPENSATION 'INSURANCE ON FILE WITH-SJLHD? <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ® DESTRUCTION N <br /> WELL CHLORINATION D WELL ABANDONMENT 0 OTHER-0 <br /> PUMP INSTALLATION B— -PUMP REPAIR 0 PUMP REPLACEMENT Q °a <br /> ;DISTANCE TO NEAREST: SE"PTIC TANK SEWER LINES PIT N <br /> ' PRIVY. <br /> SEWAGE DISPOSAL TEED CESSP PIT <br /> PIT OTHER <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC DO ESTIC :WECL <br /> - INTENDED USE TYPE OF_WELL... <br /> Industrial � CONSTRUCTION SPECIFICATIONS <br /> Gia le (Tool Dia. of Well Excavation <br /> Domestic/private Drill�� Dia, of Well 'Casing <br /> Domestic/.public �i�ven Gauge of Casing <br /> ' rrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection <br /> - RotaryType of Grout <br /> ,Disposal �" . , ter Other Information <br /> ya�-Ge"ophysiE <br /> � r` '� urface S �IIns�t_alTe_�d <br /> PUMP INSTALLATION; Contractor <br /> Type <br /> of,. p <br /> H.P. , <br /> PUMP REPLACEMENT: ❑State WorkDone <br /> PUMP REPAIR: , <br /> ❑State Work; <br /> t DESTRUCTION OF WELL; Well Diameter 4 <br /> a�Approximate Depth <br /> Describe Materia an Proce ure <br /> ► I hereby certify that I have prepared this application and that the work will be done in accordanc4 <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 C lifornia. <br /> ' TWILL CALL OR-A GROUT INSPECTI N P IOR GROUTING AND INAL INSPECTION. <br /> SIGNED <br /> / f TITLE: DATE: <br /> R P L N <br /> ON REVERSE SIDE <br /> PHASE I OR DEP TMENT SE ONLY <br /> PPA-�LICATION ACCEPTED BY <br />(ADDITIONAL COMMENTS: DATE l <br />' PHAS.E,I,IGROUT INSPECTION <br />;INSPECTION BY. DATE Na o PHASE_I_I_T:.F-I:NAL_I.NSpECT10N <br />'EH 14 26 <br />` INSPECTION 8Y 3 <br /> Rev.: 9/78 <br /> DATE <br /> - �-'— <br />