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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE *USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 3 <br /> Telephone:'' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued e/-/d,7 9 <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 /> ,oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. Pik 6 ?. � Cu <br /> EXACT STREET ADDRESS . — ` CITY/TOWN <br /> Owner' s NamePhone �1 <br /> Address City <br /> Contractor's Name LicensecZQ�3 Phone <br /> IS CERTIFICATE OF WORKMAN'S rnMPENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL(V DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD49,of/- CESSPOOL/SEEPAGE PIT OTHERu50 <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 PgaP Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal "q"" A <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 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 CAL FOR A GR INSPECTION PRI TO GROUTING AND A FINbt INSPECTION. <br /> SIGNED TITLE: DATE: a <br /> W PLOT PZAN ON REVERSE SIDE <br /> PHASE I <br /> FORD ARTMENT USE ONLY <br /> _ <br /> APPLICATION ACCEPTED BY �, �. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP TION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY_A DATE 7— 6 <br /> 7a <br /> EH 1426 Rev. 12-77 <br /> - :1 °' � x/78 2M <br />