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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br />--EOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.:7q-,—/SSS <br /> Telephone: (209) 466-6781 Date Issued1/-,/,28' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name ��7�/ ,,_ Phone36 <br /> Address _ Ci ty �-f,��.' <br /> Contractor's Name License# G 1-.3) Phone d r <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ --- - <br /> PUMP INSTALLATION El PUMP REPAIR O PUMP REPLACEMENT El <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 USETYPE 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 ��", //,tom H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: OState Work Doneti --Q <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." 11,7' ' <br /> I WILL CAW FOR A GROW INSPECTIO PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE: !�� DATE: <br /> DR W PLOT PLAN ON REVERSES E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY A DATE�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /�, /�r' DATE <br /> EH 1426 Re 2-77 1/78 2M <br />