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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> —EVLOFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, CA 95205 Permit No. <br /> Telephone: . (209) 466-6781 <br /> ��� Date Issued U, 17q <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 /> AACT --STREET ADDRESS CITY/TOWN <br /> Phon - <br /> ame <br /> Address City q- e_ - <br /> Contractor,'s Name License �3 Phon <br /> IS CERTIFICATE -OF WORKMAN'S COMPENSATION INSURAINCEFON FILE WITH SJLHD? YES NO- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION C] DESTRUCTION <br /> WELL CHL INATION WELL- ABANDONMENT 0 OTHER El <br /> PUMP INSTALLATION PUMPAREPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINTS. .7--7 ,PIT PRIVY <br /> SEWAGE DISPOSAL FIELD f CESSP OL/S- ' � PIT OTHER J <br /> F PROPERTY LINES RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS. <br /> Industrial # Cable Tool Dia. of Well Excavation <br /> Domes tic/private __ Dril-led w Dia:-af'We11`�Casing <br /> Domestic/public "' �_- Dr-i-ven _ Gauge-ofCasings a Gd <br /> Irrigation Gravel Pack-,.,. Depth,, of Grout Seao <br /> Cathodic Protection\ Rotary 1 Type of GroufSegZ �N >` <br /> Disposal 4 Other { 'Other Information <br /> Geophysical S°urface Seal Insta ledb <br /> } INSTALLATION: Contractor�l S AJ~ ' _/- <br /> PUMP �e <br /> Type of Pump ": H.P. <br /> t <br /> PUMP REPLACEMENT: []State Work Done -` <br /> il <br /> PUMP REPAIR: []State. Work Done <br /> DESTRUCTION OF WELL: Well 'Diameter Approximate./Depth.. <br /> Describe Material and Proce ure <br /> I -hereby certify that I have prepared this 'applicati•on and-.th't�the:,work wild be\don,e, in accordant <br /> with 'San Joaquin County Ordinances', State Laws;and Rules and,,Regul ati ons o�f.:_the-`San Joaquin Local <br /> f Heal the Qi s t r i ct -Home owner or 1 itensed agent's s gnaturecerti i-es-the"'foI 1 owing p <br /> "Icertify that in the performance of the wor`:k...for_.whi-phi-s°'permit is issued, I shall <br /> not employ any.persdn,i-n such manner_as-to-become subject to Workman's Compensation <br /> laws, of California." <br /> I WILL' ;CALL FOR A G OUT ,INSPEC ION PRIOR. TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED " r' TITLE: F - DATE: <br /> (DRAWL ON REVERSE S DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , - <br /> APPLICATION AGCERTED -BY. 41 � - � ��' � • <br /> ; :,` r ,. � :�moo' , DATiE <br /> ADDITIONAL COMMENTS: 1 . <br /> t PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> IFNSPECTION BY 05/ . DATE 45' ' ? INSPECTION BYE DATE B"" 1' <br /> L-EH 14 26 Rev. 9/78 ca�,9/78 - 2M <br />