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SAN JOAQUIN LOCAL HEALTH DISTRICT ° <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> .w <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Hate Issued!-/S-?g— <br /> (Complete <br /> ssued 7-/S--7(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 /> District. /l <br /> EXACT STREET ADDRESS �7 <br /> . 44 <br /> CITY/TOWN -' <br /> Owner's Name IdIF <br /> Phone ? <br /> Address44 <br /> '® <br /> Contractor's Name � ceu©ct., license# Phone 15_IKE7-:7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD7 YES NO <br /> TYPE OF WORK (Check) : NEW WELL40 DEEPEN ❑ RECONDITION Q DESTRUCTION[� <br /> WELL CHLORINATION [3 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION ,R PUMP REPAIR 0 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSP OL/SEEPAGE OTHER C <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTICEIS LL <br /> INTENDED USE TYPE OF-WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Wel] Casing Lrr <br /> Domestic/public ,. Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br />,_ Disposal ,. Other Other Information <br /> Geophysical Surface Seal Insta e b : <br /> PUMP INSTALLATION: Contractor Q�u '� I <br /> Type of Pump J H. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMA REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Proceaure <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 /> lfnot employ o <br /> p y an y person in such manner as to become subject to Workman'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: ` <br /> DR PL T L ON REVERSE SIDE <br />)RASE I FOR DEPARTMENT USE ONLY <br /> PP�LICATION ACCEPTED BYd 4, DATE rZ / 72 <br /> kDDITIONAL COMMENTS: o <br /> PHASE II GROUT INSPECTION s2 arc 2 <br /> NSPECTION BY DATEPHASE III 'FINAL INSPECTION <br /> INSPECTION BY DATE /o <br />:H 14 26 Rev. 9/78 ,, _ . 0itiQ <br />