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Ar " � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE 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?�2 <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 Heal`C� <br /> District. <br /> kc � � f 1. f " r� <br /> EXACT STREET ADDRESS Iq TY/TOWN <br /> Owner's Name � ;� Phone <br /> Address ? a ! S ��c ��� ' City <br /> Contractor's Name -" Licenser 7),j Phone L6: k -� ,re 7 G <br /> IS CERTIFICATE OF WORKMAN'S COOENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION 0 DESTRUCTION( <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER( <br /> PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT C! <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 114 <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. 7 <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: gState 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 PRIQR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED / t, r: , <br /> ,.. � � TITLE: P-f' _ DATE: <br /> DRTWPL ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ?� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II IN L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY W DATE <br /> EH 1426 Rev. 2-77 11 1/78 2M <br />