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�. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave: ,_ Stockton, CA 95205 Permit No - <br /> Telephone (209).- 466-6781 <br /> -� Date Issued6--,�9-7 <br /> APPLICATION FOR WELL. CONSTRUCTION. OR PUMP PERMIT <br /> a .. <br /> (Complete In Triplicate)_ <br /> Application is hereby made tothe San Joaquin Lod Health Distritt` 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. 1.1862 and the Rules and. Regulations of the-•San Joaquin Local Health <br /> r 26s�7o--12� I <br /> 'District. �3°v's" s s� �� `. ,�D # <br /> .EXACT STREET ADDRESS SA - 3 6 CITY/TOWN <br /> 'Owner,'s Name Phone - ' <br /> :address -,City . <br /> 'Contractor's Name License_ Phone y. <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOtl itISUR I10E ON FILE WIT�I SJLHD? YES 0 <br /> TYPE.OF WORK (Check) : NEW WELLI4 DEEPEN L RECONDITION DESTRUCTION <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHER( <br /> w PUMP INSTALLATION,M PUMP REPAIR 0 PUMP REPLACEMENT Q <br /> ' DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES r. PIT PRIVY <br /> SEWAGE DISH M ELD C SPL/SEEPAGE IT OTHER =- <br /> PROPERTY LIN6�4PRIV T D ESTIC WELL r PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Ve-1 Excavation '•' <br /> Domestic/private Drilled Dia. of Well„Casing <br /> _ Domestic/public Driven Gauge of Casingj G <br /> Irrigation 1 Gravel Pack Depth of-,GroutSea <br /> -Cathodic Protection Rotary .Type of Grout <br /> _ Disposal Other - Other Information T M <br /> ; f.. Geophysical w Surface 'Seal Insta ed b <br /> PUMP - INSTALLATION: Contractor , <br /> C Type of Pump H. : <br /> PUMP REPLACEMENT: M State .Work Done, ' ' <br /> PUMP REPAIR: O State Work ,Done <br /> Approximate Depth <br /> 15ESTRUCTION OF WELL: Well Diameter pP <br /> DescHbe-'Mate'rial- and Procedure <br /> I hereby certify that I,havelprepared 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 certifi 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 G . T ",VECTION PRIOR TO GROUTING AND A" FINAL INSPECTION. <br /> SIGNED TITLE: DATE: / <br /> PL ON REV" S SIDE <br /> OR DEPARTMENT USE-ONLY <br /> PHASE I <br /> _NPPLICATION ACCEPTED BY DATE �z <br /> `ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III N <br /> INSPECTION 8Y DATE INSPECTION BY CHFn�0'71l 7 <br /> `EH 14 26 Rev. 9/78 � fiovci,�7�i <br /> ta <br /> 7.8 2M <br />