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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> sFQB OFF7ICE USE: 1601 E. Hazelton Ave.' , Stockton, CA 95205 Permit No. <br /> 4 Telephone: (209) 466-16781 <br />� Date Issued �-/'-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate <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 /> Joaquin County Ordinance No. - 1862 .and the Rules and Regulations of the-San Joaquin Local Health <br /> i District. <br /> E �� w/� <br /> EXACTACTSTREET ADDR S IS 6 CITY/TONIN <br /> 3 <br /> Owner's Name .•u - r Phone -07 <br /> Address . City <br /> Contractor' s Nam Li cense#.���va�� Phone � ��_ <br /> IS CERTIFICATE OF WORKMAN'S CG""PENSATIOlka I�ISURA.ICE ON FILE WITH SJLHD? YES ANO <br /> f TYPE OF WORK (Check) : NEW -WELL CI DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> _ WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER❑ - <br /> PUMA INSTALLATIONq PUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTICTANK SEWAGE DISPOSAL FIELDSEWER LINES <br /> CPRIVY <br /> ESSPOOL/SEEPAGEPIT 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 /> Domestic/public Driven Gauge of'''Casl-n <br /> Irrigation Gravel Pack Depth of `�Gr-outgSeal <br /> Cathodic Protection , Rotary _ Type of of Grout: <br /> Disposal Other Other �Informat1on <br /> Geophysical Surface-Seal—Nit ai-1 d b'_: - -�--� <br /> PUMP INSTALLATION: Contractor �,�J <br /> Type of Pump H.P. <br /> S`r <br /> PUMP REPLACEMENT: ❑State Work ne <br /> 4 <br /> PUMP. REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate. Depth <br /> Describe Material and Procedure <br /> I . <br /> I hereby certify that I ,.have prepared this application and that the work will be done in accordan, <br /> r with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loca <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 FOR A GR T SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLTN ON REVERSE SIDE <br /> _ FOR DEPARTMENT-USE ONLY <br /> PHASE I .-. ._--. .- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_-I U FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --7 <br /> , .Ile n_':. ,� -1/78. 2M <br />