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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br />_ FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued z/ ' <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 />,'oaauin County Ordinance No. 1862 and theRulesand Regulations of the San Joaquin Local Health <br /> EXACT STREET ADDRESS�/^"'� L-�- ✓' CITY TOWN <br /> Owner's Name — CrJ 1 _ a �Phone_7! <br /> �.� <br /> Address - v fc' Cit � J <br /> Contractor's Name A U—L-,7—P PO P'y �'=� License e Phone 'IA./ D-f— <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONM NT p OTHER 0 _ s <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT �J <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: CIState Work Done <br /> PUMP REPAIR: 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 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: <br /> A ,a VDATE: y �Z <br /> (DRAW PLOT PLAN ON REVERSE IS D <br /> OR DE RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Y DATE G <br /> ADDITIONAL COMMENTS: <br /> - <br /> PHASE II GROUT INSPECTION PHASE- IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE gJ108 <br /> EH 1426 Rev. 12-77 1/78 2M <br />