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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br />} FFIGE USE: 1601 E. Hazelton Ave. ,..5tockton, CA 95205 Permit No.'s <br /> Telephone: ..(209) 466-67811 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue�I - .3.� <br /> (Complete -In Triplicate). <br /> Application is hereby made to the San Joaquin Local -Health District for a permit to construct f <br /> install the. work herein described. This application is made in compliance with San x <br /> Jaaquin County Ordinance No. 1862 and the Rules and RegUlations- of the San Joaquin Local Health <br /> I District. N, <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name 6'9 /h Phone l 1 <br /> 6 Address -..City �.z�- 01 <br /> :. <br /> I - ----- <br /> CN <br /> Contractor's Name License Phone 9�� j <br /> _ <br /> ?S CCERTIFICATEOF WORKMAN'S -COMPENSATION INSURA"10E ON FILE WITH SJLHD? YES COI <br /> �€ 0 <br /> j- MC, <br /> ,..- .- <br /> '"TYPEOF"W{} K " Check NEW WE_ <br /> LL DEEPEN ❑ RECONDITION ® DESTRUCTION <br /> WELL CHLORINATION p WELL ABANDONMENTf OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR d PUMP REPLACEMENT �C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSA IELD CESSP OL/SEEPAGE PIT OTHER <br /> 'PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DMESTIC WELL <br /> • INTENDED :USE TYPE OF .WELL.-. CONSTRUCTION SPECIFICAT3IONS <br /> _. Industrial Cable Tool Dia, of Well Excavation if <br /> Domestic/private Drilled Dia. of Well Casing ; <br /> Domestic/public Driven Gauge of Casing 3 <br /> Irrigation r Gravel Pack Depth of Grout Sea 1� r <br /> _r,i Cathodic Protection Rotary Type of Grout 0 <br /> I � DisposaT Other Other Information i <br /> Geophysical, Surface -Seal InsLaTTed <br /> PUMP INSTALLATION: Contractor { .: <br /> Type of Pump H.P.- <br /> PUMP <br /> .P.PUMP REPLACEMENT: El State Work Done - <br /> PUMP REPAIR: ❑State Work Done � . <br /> DESTR'L�CTION OFWLLT.- Wel 1Dlameter `� '.. x "�`�`"` /-- <br /> f O Appr ximate De th1 - <br /> Describe Mater a and Proce ure r'~ ; J <br /> ' I hereby certify that I have prepared this application and that the work will be donellin accordance: <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San-Joaquin Local i <br /> ; Health District-. Home owner or licensed agent's signature certifies the following: 1 <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> ` - not employ y an y person in. such manner as to become subject to Workman's Compensation <br /> laws of California." <br /> I WILL. 0 FOR A GROUT I SPECTION IOR- TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Cd: DATE: q <br /> PLT L ON REVERSE IDE t <br /> !PHASE I FOR DEPARTMENT-USE ONLY <br /> PPS LICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE _ <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE i INSPECTION BY D TE <br /> EH 14 26 Rev.= 9/78 <br /> ti- <br />