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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA' 95205 Permit No.7f-- <br /> Telephone: (209) 466-678 f <br /> 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issue d30 <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 /> and/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 /> District. <br /> EXACT STREET ADDRESS / 7c, 21 /1 &, -T CITY/TOWN <br /> Owner' s Name _ Phone 9T/ f� Q <br /> Address City <br /> Contractor' s Name License Phone,I&/ L^ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES �C. � --AVO <br /> TYPE OF WORK (Check) : NEW WELL93--- DEEPEN ❑ RECONDITION [] DESTRUCTION( <br /> WELL CH*ORINATION ❑ WELL ABANDONMENT ED OTHER 0 <br /> �W PUMP ITALLATION PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPT ICRNK EWER LINES PIT PRIVY <br /> SEWAGE DIS OSAL FIELD CESSPOOL SEEPAGE PIT OTHER` 9 ' <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 /> Domestic/private Drilled Dia. of Well Casing VIf <br /> Domestic/public Driven - Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Sea] �� <br /> Cathodic Protection � X Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ f H.P. / <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State 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 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 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: DATE: Q <br /> DR W PLOT PLXWON REVERSE SIDE <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _.� � DATE 3o, 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE IJ GROUT INSPECTION PHASE III FINAL INSPE TION <br /> INSPECTION BY DATE INSPECTION BYT �I�✓� <br /> X1426 Rpv_ 12-77 _ ` 1178 2M <br />