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/ SAN JOAQUIN LOCAL HEALTH DISTRICT --- <br />--FOR OFFICE USE: t 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone (209) 466-6781 <br /> 40H, APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS <br /> Owner' s Name �� '�` Phone .7 6 V7 2 s'6? <br /> Address g zz '— City <br /> Contractor's Name � �! � Li censoff Phone <br /> _,I S <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION L❑ PUMP REPAIR❑ PUMP REPLACEMENT ( <br /> DISTANCE TO NEAREST: SEPTIC TANKe 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 l <br /> Irrigation Gravel 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: []State 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 accordanc <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulatios of the San Joaquin Local <br /> Health District. Home owner or licensed agent's signature certifies th 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 `Q TITLE: DATE:agm2y� 2!V <br /> DR PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />.PHASE I q/ <br /> APPLICATION ACCEPTED BY =' DATE 9 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPEETION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY^ ,��� DATE i <br /> FH 142fi RAv_ 12-77 /7A 9M <br />