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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,Iq -1 <br /> Telephone: (209) 466-6781 Date Issued` -1 -`7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires I 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 /> District. <br /> EXACT STREET ADDRESS zCITY/TOWN <br /> Owner's Name Phone <br /> Address Ci ty7�.J <br /> Contractor's Name Gf,.° sem a License#?6(r9z/ Phone �• <br /> IS CERTIFICATE OF WORKMAN'S CO!1PENSATIO`! I'NSURAINCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION [ DESTRUCTION <br /> WELL CHLORINATION <br /> WELL ABANDONMENT Q OTHER n <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT_D4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> Industrial Cable Tool Dia. of We11 Excavation <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 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor ��so� �G H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done AMAW t�G4�" � <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 accordanc <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of theSan J aquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the follow in <br /> "I certify that in the performance of the work for which this permit is issue shall <br /> not employ any person in such manner as to become subject to Workman's Compe on <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - DATE: <br /> TITLE• <br /> DR W PLOT PLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Wil} 'r DATE �-- <br /> APPLICATION ACCEPTED BY C� <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ? <br /> ru 1eh4 D- 19_77 _... <br />