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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1501 E. Hazelton .Ave. , Stockton, CA 95205 Permit No. <br /> f 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 Joaqui,n' Loca1 .Health' District for a permit to' construct <br /> and/car install the work herein described. - This application- is made -in compliance with San <br /> �aan.,in County Ordinance No. 1852 and the Rules and Regulations of the San Joaquin Local Health <br /> Gistrryct. <br /> EXACT STREET :ADDRESS v C ` CITY/TOWN �+ <br />' Owner's Dame Phone <br /> i Addresscity - <br />! Contractor's <br /> i City . <br />( Contractor's Name - <br /> I <br /> License# Phone&75= t <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJL.HD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER � <br /> P MP I ALLATI N [:3 PUMP R P <br /> E AIR, PUMP REPLACEMENT ❑ <br /> CDISTANCE 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 />'_Domestic/private Drilled Dia. .of..Well-Casing <br /> __�_ <br /> T--Domesti c/publ tc""" ve'n` _7. Gauge of Casi ng ; <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 INSTALLATION: Contractor <br /> Type of Pump H,p, <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: {State Work Done r { t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe MateriaT and Procedure <br /> 3 <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 FORA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> r <br /> SIGNED <br /> TITLE; DATE:-5;N a- C-7 <br /> DRAW PLOT PLFN ON REVERSE SIDE <br /> FOR DEPARTMENT AE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDAT E• -'" <br /> 5�� <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INS CTION PHASE II I. FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> x. 14?F P,0 V/ <br /> 19-77 <br />