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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No. — .2 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ly <br /> (complete In 'Triplicate)' . : .. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const ruct`­ <br /> :and/or install the work herein described. This appli'cation,is made .-in compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rus and RegUlations of -the-San Joaquin Local Health <br /> Districb <br /> t . <br /> EXACT STREET ADDRES CITY/TOWNIJ <br /> Owner's Name Al a , <br /> Phone <br /> Address a -Ci.ty 2.Y <br /> Contractor's Name License# 3�Phone�L <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCEJN-'-`FILE�WITH. SJLHD?._ 1'ES�-w <br /> i <br /> TYPE OF WORK - (Check) : NEW WELL M DEEPEN ❑ RECONDITION C DESTRUCTIQN <br /> WELL �CHLORINATION p WELL ABANDONMENT [:) OTHER ID <br /> PUMP. INSTALLATION [:� <br /> .. .PUMP_.REPAIRQ .-- PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i'PIT PRIVY <br /> " <br /> ' '.:'SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE..PIT. OTHER <br /> PROPERTY LINE - PRIVATETE flO ESTIC WELL PUBLIC DO ESTIC WE L d <br /> i - INTENDED USE TYPE OF -WELL.- CONSTRUCTION SPECIFICATIONS O <br /> Industrial , Cable Tool Dia. of Wefl—EXCdVatlOn. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection r <br /> - osal _.,--,.Rotary' Type of, Grout <br /> Disposal <br /> - <br /> p Other `` � `; 'Other. Information <br /> Geophysical Surface Seal Installed, <br /> PUMP INSTALLATION: . Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: t <br /> Mate Work Done <br /> PUMP REPAIR: ' i. o , <br /> _ ❑State Work Done <br /> DESTRUCTION OF WELL: WeII Diameter <br /> 1 <br /> Describe Materia and Procedure Approximate Depth. <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' ` Y"' <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws -of California. " `ate'' ► <br /> I WILL CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING- AND A F=INAL INSPECTION. <br /> SIGNED . TITLE: - DATE: <br /> DR W PLT L N ON REVS SE SIDE i <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> 4PPLICATION ACCEPTED BY DATE /� 7 <br /> NDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY . PHM 111 "FINAL INSPECTION <br /> DATE INSPECTION BY DATE q -GALA- 11 <br />:H 14 26 Rev. 9%7g - 9/78--_.- 2M <br />