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SAN JOAQUIN LOCAL: HEALTH -DISTRICT <br /> FFICE U-SE: 1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. `7� - ylr� <br /> Teleph Qe. ....{209} 466-6781 a . <br /> APLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,5 <br /> f 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 /> sand/or install the, work herein described. This application is made in compliance with San <br /> ,oanuin County Ordinance No. 1862' and the Rules 'and Regulations of the San. Joaquin Local Health� <br /> ''listricr <br />, EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone3. =w� <br /> Address .� . Y.� // City <br /> Contractor' s Nam j Licenseggo Phone <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA C.E`ON'FILE WITH SJLHD? YES NO <br />` TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />(! DISTANCE TO NEAREST: SEPTIC TANK SEWERiLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDS 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 /> c D estic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection L­Wtary Type of Grout <br /> Disposal , ,,- Other Other Information f <br /> Geophysical Surface Seal Instal ed b <br />.PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I <br /> PUMP REPLACEMENT: ❑ State Work Done <br />'PUMP REPAIR: JF, ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> r <br /> I hereby certify that I have prepared this application acid 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 the­work' 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: DATE: <br /> DR W PLOT PLAN- ON REVERSE SIDE <br /> . _, FOR DEPARTMENT USE ONLY <br /> PHASE _.J <br /> APPLICATI-ON.ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f <br /> PHASE'-II°- ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECThON BY DATES �-6/71 <br /> f <br /> EFi_1426 :Rec. 12-77' <br />