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Cc kA SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F I E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - O <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -9-7 <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 �f h `�• �n Sob ��,o CITY/TOWN <br /> Owner's Name Phone <br /> Address o2 �. Ci ty . a <br /> Contractor's Name License# hone o�—�76 <br /> IS CERTIFICATE OF WORKMAN'S COMP A ION INSURANCE ON FILE WITH SJL D? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [3 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR W PUMP REPLACEMENT CI <br /> q _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL F ELD CES UL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL--- PUBLIC DOMESTIC WELL <br /> c. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WeTT Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br />- , Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed b -� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 7 H•P. <br /> a - <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: PState Work Done o ct <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 INSPEC=N RRIGROUTING AND A FINAL INSPECTION. <br /> 1-1 SIGNED LE: a�rcJ' DATE: <br /> WAWPL N REVERS SIDET <br /> FOR DEPARTMENTUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1;2Z71-7y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY N/A ---- DATE INSPECTION BY j-, DATE ? -> <br /> .. . <br /> EH 14 26 Rev. 9/78 M <br />