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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. '-r q - 65/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6-2-o -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. _p <br /> EXACT STREET ADDRESS CITY/TOWN e� �T <br /> Owner's Name &'7f Phone <br /> Address City <br /> Contractor's Name J. License## 7,67� Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSUR I•!CE ON FILE WITH SJLHD? YES NO' <br /> TYPE OF WORK (Check) : NEW WELLUa-"- DEEPEN ❑ RECONDITION [Q DESTRUCTION( <br /> WELL CHLORINATION Q WELL ABANDONMENT Lam'" OTHER 0 <br /> PUMP INSTALLATION ga-*� PUMP REPAIR 0 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK Q r/`SEWER LINES�e_'151IT PRIVY <br /> SEWAGE DISP F.F�t ELD CESSPOOL/SEEPAGE PIT/� 7`-OTHER <br /> -_-PROPERTY LIN 'PRIVATE DOMESTIC WELL-5�PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 7_.!�f 4 (D <br /> Domestic/private /Drilled Dia. of Well Casing . <br /> Domestic/public riven 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 Installed by: _S' <br /> PUMP INSTALLATION: Contractor Ale 7.0r. ` �f4rf <br /> Type of Pump , .. H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter =�/ V79-T7Approx mate .Depth <br /> Describe Mate-r-T-al and Prowure <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 GROU INSPECTION PRIOR TO GROUTING AND A F NAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DL EV SI E <br /> PHASE I <br /> R DEP TMEN USE ONLY <br /> -' <br /> PPS LICATION ACCEPTED BY DATE 6' <br /> ADDITIONAL COMMENTS: <br /> PHASE <br /> VIII GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY__� - - DATE INSPECTION BY l DATE <br /> EH 14 26 Rev. 9/789 8 2M <br />