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-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FF CE USE: 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No. ' `1=.3 76 <br /> Telephone: (209) 466-6781 <br /> 1775,06-1 1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 /> EXACT STREET ADDRESS �' ,(a / j�j a CITY/TOWN <br /> Owner's Name 1r,--1 f e ��,e 1, „-�, Phone <br /> Address <br /> . , t.rJC i tY <br /> Contractor's Nam License#/q.;�7-ys� Phone d ?6 <br /> _IS CERTIFICATE OF WORKMAN'S C0 EN ATION INSURANCE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN 0 RECONDITION Q DESTRUCTION rl � <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 Cp- <br /> PUMP INSTALLATION (,gJ PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _, PIT PRIVY <br /> S—AL <br /> SEWAGE DISP TIELD CESSPOOL/SEEPAGE PIS OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL.._._. PUBL C DOMESTIC WELL — S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -- Cable Tool Dia. of Well Excavation <br /> ___,X_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 y: <br /> PUMP INSTALLATION: Contractor "' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP Rte: M State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxi to 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 GROUT INSPECT ON PR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNE <br /> TLE: DATE: ?d <br /> P" ( JtDRAW PLOT PLAUON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> WLICATION ACCEPTED BY j Z DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE \A-a5-19 <br /> EH 14 26 Rev. 9/78 9/78 2M <br />