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z'. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I FOR F ICE !;USE: 1601 E. Hazelton -Ave.., Stockton, CA 95205 Permit No. _ 3 <br /> , Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/o-3d_ <br /> This Permit Expires 1 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 /> CITY/TOWN <br /> EXACT STREET ADDRESS <br /> Owner' s Name Phone <br /> ---------------- <br /> Address I �Lic <br /> Ci.ty <br /> Contractor' s Name(S # ?3 �7 Qne__ <br /> IS CERTIFICATE OF WORKMAN'S C EN ATIO11 I�ISURA,"iCE 01,11 FILE WITH SJLHD? YES >< NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0'- -- RECONDITION C] DESTRUCTION El � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR Cl PUMP REPLACEMENT UN L4 <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 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 Pump N.P. <br /> PUMP REPLACEMENT: :`51State Work Done_ ud �� �_ . ;� ,! � - <br /> PUMP REPAIR: ❑State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Procedure <br /> I hereby _certify that I. have prepared this application and that the work will °be done in accordant( <br /> with San Joaquin County, 0rdinances , 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 or California.:" <br /> I WILL CALL FOR A GROUT INSPECTI PRIOR GROUTING AND A FINAL INSPECTION. <br /> r SIGNED 1E: DATE: � <br /> D PL W PL N REVERS£ SID-E) <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I DATE 7 <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL- COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> : INSPECTION: BY AylDATE INSPECTION''BYAy (Zo� <br /> 1~/78. ..2M <br /> VN 1,19A bav 17-77 �' <br />