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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued, 7 <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. 2494sr E_ ef,4kw,4,'f <br /> `� 1 �3-.moo-ate <br /> EXACT STREET ADDRESS ! N' -XzW,P G'AN CITY/TOWN <br /> Owner's Name � � �/ <br /> Phone <br /> Address _� ,f--�33 a <br /> City <br /> Contractor's Name ,VC4 e license# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE FILE WITH SJLHD? YES v 0' <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [D DESTRUCTION[� <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION El- PUMP REPAIR C,- PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOST AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WE <br /> INTENDED USE TYPE OF.WELL., CONSTRUCTION SPECIFICATIONS ' <br /> _Industrial Cable Tool Dia. of Wel Excavation <br /> ,----- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _tom rigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> .. Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump .P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done — F1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MatJ`ial and Procedure <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 C L FOR A GROUT NSPECTION PRIOR TO GROUTING AND A INAL INSPECTION. <br /> SIGNED TITLE: _ . <br /> DATE: <br /> R W L L ON REV R E SIDE-),-- - ___ ... <br /> PHASE I R DEPARTMENT USE ONLY <br /> �n <br /> PPLI ATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE TI GROUT INSPECTION PHAI INSPECTION <br /> INSPECTION By DATE INSPECTION BY <br /> EH 14 26 Rev. 9/78 -4 DATE -2 -Y <br /> 9/78 2M <br />