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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> [:iFFICE USE: 1 1601 E. Hazelton Ave. Stockton., CA 95205 Permit No. 79 <br /> Telephone: (209) .466-6781 <br /> TPAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued,5% -2 <br /> (Complete In Triplicate) <br /> n� <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 /> District. <br /> EXACT STREET ADDRESS CITY/TOWN �� , . <br /> Owner's Name Phone <br /> Address1A2 L_ <br /> City �•rz_�___ . <br /> Contractor's Name <br /> ELi cense#Z110_/23_7 Phane_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WJ.Th-SJLHD? YES ^ 0. <br /> -_-�- -� .. — _��..�_ .--�----,_-� <br /> t TYPE OF WORK (Check) : NEW WELL 0' DEEPEN ❑ RECONDITION DESTRUCTION d <br /> WELL CHLORINATION ❑ WELL ABANDONME T ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL1SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC -WELL PUBLIC D MESTIC WE1T <br /> INTENDED USE TYPE OF-WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool .Dia. of Well Excavation 4- <br /> Domestic/private Drilled Dia. of Well Casing -- <br />' Domestic/public -Driven Gauge of Casing <br /> Irrigat-ion Gravel Pack Depth of Grout Sea <br /> .;�� Cathodic,Protection Rotary Type of Grout <br /> I Disposal _ Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: -LBState Work Done <br /> FDE5TRUCTIQ.N_OF_WELL• i—Wel_1-Di-ameter- _ - �-- �- <br /> Approxi-mate7Depth- <br /> Describe Materia and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health Distri.ct.. 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 <br /> TITLE: DATE: ,.. <br /> DR W PL T PL N ON REVERSE SI <br /> 11PHASE I /FOR D PARTMENT USE ONLY <br /> PPPLICATION ACCEPTED BY. DATE <br /> •ADDITIONAL COMMENTS: <br /> PHASE Ilt GROUT INSPECTION <br /> INSPECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE —�2 {? <br /> EH 14 26 Rev. 9/70)* /78 2M <br />