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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -- 1 <br /> Telephone: (209) 466-6781 <br /> 4� Q P14) 4-z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 /> F District. <br /> E <br /> EXACT STREET ADDRESS 3 1 0-1 <br /> C TY/TOWN Ste, <br /> Owner's NamPhone ...- <br /> a A9 �Z— 27 6f' <br /> Address p derr Ci ty S e � <br /> E Contractor's Name vLicense#jf16(Phone <br /> � 3� <br /> IS CERTIFICATE OF WORKiiAN'S COMPENSATION INSURA"� ON FILE WITH SJLHD? YES 0" <br /> TYPE OF WORK (Check) ; NEW WELL[] DEEPEN ❑ RECONDITION [n DESTRUCTION <br /> } <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0'. PUMP REPLACEMENT [9 �j <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />' SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PI� OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WE L l <br /> INTENDED Ut� ' ; TYPE OF WELL._ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - Domestic/privAe Drilled Dia. of Well Casing <br /> Domestic/public /,, Driven Gauge of Casing <br /> .�- Irrigation . Gravel Pack Depth of Grout Sea. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal -«—Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: ' Contractor <br /> t;T-ype of Pump <br /> PUMP REPLACEMENT: Ej State Work Done <br /> PUMP REPAIR: � - <br /> OState Work Dane <br /> DESTRUCTION OF WELL: =We 11 Diameter__. - --�. � `- .�, :� �pproximate"Dpth <br /> { 3y Describe Materia and Procedure <br /> I hereby certify that I have prepared this application and that the world will be done in accordance <br /> with San Joaqu',. County Ordinances , State Laws , and Rules an& Regulations of the San Joaquin Local <br /> Health District. Home owner or 1icensdd. .agent's signature certifies the "following: <br /> "I certify that °-in the performance 'of the work for which thit permit i,s° issued, I shall <br /> i not employ any person in such manner as' to become subject to`SWorkman's�Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT SPECTION PRIOR TO GROUTING .AND FINAL INSPECTION. <br />.SIGNED TITLE' DATE: 9 <br />{ DR W P L ON RE RSE SIDE <br /> PHASE I <br /> ZF DEP RTMEN USE ONLY <br />°APPLICATION ACCEPTED ,BY �• DATE 6 <br />(ADDITIONAL COMMENTS: . <br /> 4r, 47 <br /> PHASE II GROUT INSPECTION PHASE III.;-FINAL-INSRECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> tEH 14 26 Rev. 9/ F, 9/78 2M <br />