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SAN JOAQUINLOCAL HEALTH DISTRICT <br /> OFFICE 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 JoZ 7 <br /> This Permit Expires 1 Year From Date .Issued <br /> Complete In Triplicate <br /> , y <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 with San <br />,oaouin County Ordinance 1�o. 1862 and the Rules and -Regulations of the San Joaquin. Local Health <br /> District <br /> EXACT STREET ADDRESS 3 CITY/TOWN <br /> Owner' s Name Phone <br /> Address City Z24-& r� <br /> Contractor' s Name, License# 7/ Phone 933 —ZL8-1K <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA*10E ON FILE WITH SJLHD? YES iC NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <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 />---)L-Domestic/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 1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed _by: <br /> c <br /> PUMP INSTALLATION: Contractor <br /> C�CY1iiR. . <br /> Type of Pump_ H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: QState-Work._Done. ' <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 /> gith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ' <br /> dealth 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 A GRO T NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: - /-7� <br /> ____(DRAW PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT US ONLY <br />)RASE I i <br /> APPLICATION ACCEPTED BY4 DAT <br />\DDITIONAL COMMENTS : <br /> PHASE Ii GROUT INSPtCTION PHASE III FINAL INSPECTION <br />;NSPECTION BY DATEINSPECTION BY <br /> H 142A Ppv 1977 1 /7R 9M <br />