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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF1C( USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. "7 9-7 <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued']- <br /> This Permit. Expires 1 Year From Date Issued <br /> Complete In Triplicate •• 2u._ o,zt <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,:oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distract. N-w eoreNEn oorESc,►4•y 8.-,uo7�9Y, /Itz�M Rd <br /> EXACT STREET ADDRESS , CITY/TOWN) <br /> Owner's Name A, Phone <br /> Address Ci ty ZSCA.Cd �T <br /> Contractor's Name License&22! i? J� Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? -YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAI.RPUMP REPLACEMENT ❑ 1 <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 Well Excavation <br /> Domestic/private Drilled - Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack �J� 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 - <br /> Type of <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: [RStatt.e_Work Done Q / �-- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <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 /> 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 GROUT�INSPTION PRIOR TO GROUTING AND A FINA INSPECTION. <br /> SIGNED TITLE: DATE: <br /> —__(DRAW PLOT PLAY ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 3 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION / PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE GC/ INSPECTION BY DATE <br /> E , <br /> EH 1426 Rey. 12-77 r 1 /78. 2M <br />