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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone:. . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued 3 s <br /> l <br /> This Permit Ex fres 1.. Year From Date Issued . <br /> I Complete In Triplicate <br /> Application is hereby made to the San Joaquin.'Local Health District for a permit to construct' <br />.land/or.,install ' the work herein described. This application is made in compliance with San <br /> Fk_oamuin; County Ordinance 111o. - 1862 and - the Rules and Regulations of the San Joaquin Local Health <br /> �istrc't. <br /> EXACT STREET ADDRES CA/ CITY/TOW <br /> N <br /> Owner's Name -- Phone <br /> Address <br /> C i ty <br /># � -�C : - _ <br /> Contractor's Na j /a�. f r ` Liceris 90Phone ` <br /> IS CERTIFICATE OF WORKMAN'S COf"PENSATIOkJ INSURANCE 0P3 FILE IrJITH 5JLHD? YES <br /> TYPE OF ,WORK (Check_) :, NEW WELL CI DEEPEN ❑ RECONDITION Q DESTRUCTIONS a <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER <br /> PUMP INSTALLATION gJ—" PUIMP REPAIR p PUMP REPLACEMENT Q <br /> IDISTANC�E TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -�' ON <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 /> ustrial Cable Tool Dia. of Well Excavation <br /> E Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing •s <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal er Other' Information <br /> Geophysical :.,Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of p y H.P. _= <br /> ,PUMP REPLACEMENT: [3 State Work Done <br /> ' PUMP REPAIR: ❑State 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 accordant <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulati.,ons_ 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 y <br /> .laws of � ifornia." <br /> I WILL CALL OR A GROUT INSPECT0 N :RIO TO GROUTING AND AFOAL INSPECTION. <br /> tf <br /> TITLE: <br /> SIGNED <br /> DATE <br /> RAW LOT PLAN ON REVERSE. SIDE <br /> F FOR DEPARTMENT USE ONLY <br /> `PHASE I Q <br /> APPLICATION ACCEPTED BY DATE �S�J <br /> ADDITIONAL COMMENTS: `. <br /> PHASE II,GROUT ;INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY : DATE INSPECTION BY _j )ATE <br /> ,r .�. 1 /78 2M <br /> FIS 1 ff2r, Rav 12-77 - <br />