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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,FOR OFFICE USE. /1601 E. Hazelton dare. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I Date Issued, <br /> This Permit Ex fres 1 Year From Date Issued <br /> (Complete In Trip icate `. <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 CITY/TOWN se �o <br /> Owner's Name /7�,v1! y _ �/.4/E Phone <br /> AddressWAZ 21 q2:!Z 46City �� <br /> Contractor's Name Licensee Phone Q <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIT] INSUR NCE ON FILE WITH SJLHD? YES�V NO <br /> TYPE OF WORK (Check) : NEW WELLA DEEPEN 0 RECONDITION ❑ DESTRUCTION(] <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER Q <br /> PUMP INSTALLATION Q PUMP REPAIR Q PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES — PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE P'I7— OTHER <br /> PROPERTY LINJZX- PRIVATE DOMESTIC WELLSI}_'_+_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel Excavation 12 " <br /> Domestic/private Drilled Dia. of Well Casing IP Il <br /> Domestic/public _ Driven Gauge of Casing - <br /> Irrigation --4-9ravel ,Pack Depth of Grout Sea <br /> Cathodic Protection _Rotary Type of Grout 14- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Inst—ITT±Lby. <br /> PUMP INSTALLATION: Contractor r- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: (]State Work bone <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 accordanc- <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 IN EC ON P,#IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> L ON REVERM SIDn <br /> VOR-DEPARTMENT USE ONLY. <br /> PHASE I <br /> PPLIC TION ACCEPTED BY / DATE ^-2 a <br /> ADDITIONAL COMMENTS: <br /> PHASEMI GROUT INSPECTION PHASE IIR FINAL INSPECTION <br /> INSPECTION BY DATE S- 1&--7& INSPECTION BY DATE ZZ f <br /> Eli 1<. 6Rev. 12-77 CO 1/78 2M <br />