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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR OFF-ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.-2 <br /> _ go, 12e c. 71 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> ('Complete In Triplicate) <br /> \ ` construct <br /> Application is hereby made to the San Joaquin Local Health District for a permit to co �. <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 /> EXACT STREET ADDRESS ! CITY/TOWN <br /> Owner's Name (��� �� 0 ZA4c Phoneme <br /> Address City <br /> Contractor's Name License# Phone d <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANC ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL UL DEEPEN ❑ RECONDITION ❑ DESTRUCTION rl _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK /4 SEWER LINEPIT PRIVY <br /> SEWAGE DISP S IELQS_c_ �S ; L/SEEPAGE PIT OTHER <br /> PROPERTY LINI104PRIVATE DOMESTIC WELLCYd—!d.-. 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 c/ggg 1,C4 <br /> Irrigation Gravel Pack Depth of Grout Sea i <br /> Cathodic Protection __Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> _PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑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 /> f'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 FORA ROUT NS ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: _ DATE: icM t <br /> PLOT PLAN ON REV R SIDE <br /> PHASE I FOR DEPARTMENT UONLY <br /> APPLI ATION ACCEPTED BY �Z,/ DATES ,,fUr� 71 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE b,"- zi — 9 INSPECTION BY �, �3r DATE Z <br /> EH 14 26 Rev. 9/78 /78 2M <br />