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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR <br /> -OFFICE USE: 1601 E. Hazelton Jive. , Stockton, CA 95205 Permit No. ,7 ?- 6 5 <br /> Telephone: (209) 466-6781 <br /> n APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,-5- 3/-?: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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health;`'. <br /> District. -�� ,r <br /> EXACT STREET ADDRESS - o275 q?ITY/TOWN <br /> Owner's Name t A �fi"�e a Cf ?,e <br /> ����i�' � Phone ,� Y <br /> Address Ci ty_y, <br /> Contractor' s Name License b&:3 Phone - <br /> IS CERTIFICATE OF WORKMAN'S OMPENSATIO"J INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 7a, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD JD` 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: \:P, <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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FOAL INSPECTION. <br /> SIGNED TITLE: DATE: e <br /> DRAW PLOT YPN ON REVERSE SIDE <br /> FOR DEPARTMENT UGE ONLY <br /> PHASE I -- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />[NSPECTION BY DATE INSPECTION BY C DATE /17/71 <br />:H 1426 Rev. 2-77 <br /> 1/78 2M' <br />