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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR QFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2f--,&6. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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/TONIN <br /> EXACT STREET ADDRESS �� �� � ,,� �=� `�' - - <br /> Owner's Name '� ' y,, Phone - <br /> Addressr, Ci ty <br /> Contractor's Name i cense# Phone , -- � � <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSA IO"1 PdSURAT.E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL;M' DEEPEN Q RECONDITION Q DESTRUCTION C2 Q)o <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 cam <br /> PUMP INSTALLATION Ch PUMP REPAIR Q PUMP REPLACEMENT [I <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 s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool , Dia. of Well Excavation .P- <br /> Domestic/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 by: �` C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: Q 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 „Regul,ations 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 tb Workman's Compensation <br /> laws of California.” <br /> I WILL OR A GROUT—IV5PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED T TITLE: DATE: <br /> kUKAW FLU[ FUN ON REVERSE SIDE <br /> FOR D P RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 711117e- <br /> ADDITIONAL <br /> COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY D—AT—E )---ol <br /> EH 1426 R 1/78 2M <br />