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_ SAN JOAQUIN LOCAL HEALTH DI5-IKILI Permit No. <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 , <br /> �3d Telephone: (1209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued /-4 <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 /> plication . is made in compliance with San <br /> and/or install the work herein described. This ap <br />,'oaquin County Ordinance No. 1862 and the Rules a-nd Regulations of the San Joaquin Local Health <br /> 9;strict. CbC-) =. , <br /> EXACT STREET ADDRESS CITY/TOWN Sd`a C a <br /> Phone <br /> Owner's Name " <br /> Address city <br /> Contractor' s Name License#rA� Phone <br /> ?S CERTIFICATE OF WORKMAN'S CO"1PENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE, OF WORK (Check) : NEW WELLt& DEEPEN ❑ RECONDITION ❑ . DESTRUCTION <br /> WELL CHLORINATION Q WELL'ABANDONMENT p OTHER EJ -- -� <br /> PUMP INSTALLATION 5b PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK// ,rl SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USErJt TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4<v <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation -4,-Gravel Pack Depth of... Grout Seal-- Jro ' <br /> Cathodic Protection --Rotary , Type of Grout_ Al <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: OState 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 accordanc <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 FINAL INSPECTION. <br /> SIGNED TITLE: riCJr, DATE: 19— <br /> URAW PL T PL N ON REVERSE SIDE <br /> FOR EPARTWENT US ONLY <br /> f PHASE I <br /> APPLICATION ACCEPTED BY :ZJ <br /> DATE y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> I INSPECT)ON BY DATE NSPECTION BY ' QATE <br /> krW 1A0a D-- 11-77 - - 1/78 2M <br />