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SAN JOAQUIN LOCAL-HEALTH DISTRICT - <br /> FF _CE USE: 1.601 E. Hazelton Ave.. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3 - -- 9 <br /> (Complete In Triplicate), x . <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 i-s made in compliance with San <br /> Joaquin County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin' Local Health <br /> District. &ice►' J & 'P 2-0 F_ F.r�4A-7s cmc 4 c •�,�. 3—Z — 5s <br /> EXACT STREET ADDRESS G, 'Y/TOWN <br /> Owner . z <br /> 's Name t Phone <br /> Address_,26,2 City S ` <br /> Contractor's Name License# Phoney '1 - 2&I41 _ <br />-IS CERTIFICATE OF WORKMAN'S C01r1PENSATIOM INSU ANCE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN 0 RECONDITION ® DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT 0 <br /> g <br /> DISTANCE TO NEAREST: SEPTIC TANK/gip i SEWER LINES PIT PRIVY SEWAGE DISPOSAL FIELD�a� CESL/SEEPAGE PIT ----OTHER <br /> PROPERTY LINO'&4PRIVATE DOMESTIC WELL�a PUBLIC DOMESTIC WELL , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. ' <br /> Industrial iCable Tool Dia. of Well Excavation 2 " <br /> Domestic/private i Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation K Gravel Pack Depth of Grout Sea <br /> Cathodic Protection X_Rotary Type of Grout, ,Y - <br /> Disposal t Other Other Information <br />—Geophysical q Surface Seal Installed by: �( <br /> PUMP INSTALLATION: Contractor <br /> — - Type of Pump H. <br /> PUMP REPLACEMENT: CI State Work Done <br /> PUMP REPAIR: O State;Work Done <br /> DESTRUCTION OF 'WELL: Well Diameter "' Approximate Depth : f <br /> Describe Materia . an rote 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 , a-nd 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`empl.oy_any person in such manner as to become subject to Workman's Compensation <br /> law's of California. <br /> I WILL CALL FOR GRO i P/CTION PRIOR TO GROUTING AND A-FINAL INSPECTION, r , <br /> S I G N EJff�i <br /> Df TITLE: DATE: ' <br /> P N ON REVERSE' .SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APDLICATION ACCEPTED BY DATE b—71 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION -PHASE IIL JINAL4INSPECTION i <br /> INSPECTION BY DATE_ 'INSPECTION BY 7 DArT� f � <br /> EH 14 26 Rev. 9/78 l -6 / Av-e_z_,1 78 2M _.:f <br />