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F <br /> SAN JOAQUIN LOCAL- HEALTH DisT RICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ' <br /> Telephoner (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued / _ -28r <br /> This Permit Expires 1 Year. From Date Issued <br /> Complete In Triplicate <br /> . r <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 `i-s. made in compliance with- San <br /> Joaquin County Ordinance No. ; 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS >k p .v d <br /> 5.. CITY/TOWN5z�,c <br /> Owner's. Name a Phone <br /> �z <br /> Address C ,� Ctycay -- <br /> Contractor's Name `:. License# .5 &- Phone <br /> IS-CERTIFICATE OF--WORKMAN'S COMPENSAT,I,Otl''I�lSURAt.! E OtrFIIE`WITH-SJ'LHD? - YES `td0 <br />►TYPE OF WORK--(Check) : NEW WELL❑ DEEPEN ❑ - RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP ,INSTALLATION [IPUMP REPAIR(N— PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `r-e .SEWER LINESA-e� ,-, PIT PRIVY <A <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL TO <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ;• <br /> Industrial Cable Tool Dia. of Well Excavation_ s' <br /> 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 <br /> Disposal- Other Other Information <br /> Geophysical Surface Seal Installed by: <br />' .PUMP INSTALLATION: Contractor <br /> Type of Pump A I H. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ,x ❑State Work Done O&b k <br /> f <br /> DESTRUCTION OF''WELL: Well Diameter Approximate Depth <br /> fi Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that�the�woi^k. will be done in accordance <br /> with San Joaquin County Ordinances, State laws, and Rules and Regialations .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 Wor-kman-s--Compensation <br /> laws of California. " <br />, I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A ,FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 1,Q Z z _ <br /> DRAW PLOT PLTN ON REVERSE -SIDE),,(- <br /> FOR <br /> IDE FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1613 ITf <br />,ADDITIONAL COMMENTS : <br /> f PHASE II GROUT INSPECTION PHASE AII FINAL INSPECTION <br /> INSPECTION BY A/.f DATE INSPECTION BY DATE <br />[EH 1426 Rpv_ 12-77 / k P/�` z1 78 <br />