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SAN JOAQUIN LOCAL-HEALTH DISTRICT _ <br /> MCE USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No. <br /> Telephoge: (2,09) 466-6781 <br /> APPLICATION 'FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued__ <br /> ('Complete In Triplicae). . <br /> = u <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. 1.862 and the Rules and Regulations of the -San Joaquin Local health � <br /> District. <br /> EXACT STREET ADORESS j CITYffffii ^ <br /> Owner's Name r Phone <br /> Address <br /> Contractor's Name <br /> r i cense <br /> _IS CERTIFICATE OF WORKMAN'S COMPENSATIDN INSURAIN ON FILE WIT' SJLHD?- - YES 0 f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION, <br /> WELL CHL RINATION WELL ABANDONMENT DEOTHERT0 N <br /> PUMP LL <br /> PUMP REPAIR❑--_PUMP REPLACEMENT .[ s <br /> DISTANCE TO NEAREST: SEPTIC TANK�tSEWER LINES V.�.PITPRIVY <br /> SEWAGE DISPOSIELD CESSP OL/SEEPAGE PIT -OTHER.--- "--Z <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC—DOMES TIC',WELL <br /> _:_:._INTENDED-USE-- — - - _ .._ — � � � _ _.M .: <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS_ <br /> r . Industria Cable Tool Dia. of -Well Excavation ie <br /> omesti c/private l.�tTri l l ed Dia. of Wel&s n-9 <br /> Domestic/public Driven Gauge -of Casing <br /> if Agg&- ;?�.45 4 <br /> Irrigation Gravel Pack Depth of'Trou�'Sem � <br /> Cathodic Protection rotary <br /> Disposal Type .of Grout <br /> OtherM <br /> Other Information" <br /> Geophysical <br /> Surface Seal, lnstolled by. ; <br /> PUMP INSTALLATION: Contractor <br /> T f r �'� v <br /> Type o Pump Nf P. <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP REPAIR: <br /> - QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia an r e u Ylel pproximate: Depth f j <br /> I hereby certify that I have prepared this application and that the work will be done in accordance' <br /> with San Joaquin County Ordinances, State Laws , and.- Ren e- s and Regulations" of thie San -Joaqui nyy 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 />[ WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING` AND INAL' INSPECTION. <br />;IGNED TITLE: i <br /> R L L ON REVS ESI E d DATE:" <br />'HASE I FOR DEP RTMENT USE ONLY _ . <br /> IPPL ICATION ACCEPTED BY <br />�DDITIONAL COMMENTS: DATE-- <br /> PHASE II GROUT INSPECTION' _ M"` <br /> NSPECTION BYPHASE I I F SPECTION <br /> DATE INSPECTION BY DATE (o 7 <br /> H 14 26 Rev. ,9/78 . <br />