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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;2y- <br />-FOR-OFFICE USE: 1601 E. Hazelton ;Ave. , Stockton, CA 95205 Permit No. <br /> Telephoner (209) 466-67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I. Year From Date Issued / D 7� /—` <br /> Complete In Triplicate) ` <br /> i ct far a er�ni�t 'too construct <br /> Application is hereby made to the San Joaquin Local Health. Dlstr p <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joanuin County Ordinance No. 1862. and the Rules and Regulations of the San Joaquin Local Health <br /> District. 2-03 - 6?/0-1/ <br /> EXACT STREET ADDRESS jL'L'� eA <br /> c�tC.v.w cf e a -e f�ue fi7e,4riCITY/TOWN r <br /> Owner' s Name Phone <br /> Address 7 *� <br /> W . <br /> City ri <br /> Contractor' s Name Licensee' 7j�1 Phoneme- <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN ❑ RECONDITION C3 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION FEJ' PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK a� 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 /> Industr* Cable Tool Dia. of Well Excavation , <br /> Domes private Drilled . Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> '----Cathodic Protection Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical _ Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor rV5fd usi-sizgp <br /> Type of Pump , H.P. <br /> PUMP REPLACEMENT: In State Work-Done <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 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 GROUI INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Or DATE: <br /> (DRAW PLOT PLAN ON REVERSE__SIDE _ . _ <br /> FOR DEPARTMEAT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION /` PHASE III INAL INSPECTION <br /> INSPECTION BY DATE / �/ INSPECTION BY-PV DATE / 7 <br /> ,EH 1426 Rev_ 12-77 _V l W 2M <br />