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SAN JOAQUIN LOCAL IiEALTH DISTRICT <br /> QR FF E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL --CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 1 Year From Date ls'sued - <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 /> doanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin . Local. Health <br /> District. <br /> EXACT STREET ADDRESS -CITY/TOWN c <br /> Owner's Name ��� ►-,� �� ,✓,�,�✓ Phone <br /> Address - Q /3 City <br /> Contractor's Name License# Gy3 7,)-s�Phone Yl6y 16 2 6 _ <br /> I- TS CERTIFICATE OF WORKMAN'S C01 ENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br />, TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ ` RECONDITION DESTRUCTION❑ <br /> F WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION p PUMP REPAIR❑ PUMP REPLACEMENT ❑ 0 <br /> : DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> • - SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER S- <br /> PROPERTY LINE -. PRIVATE� DOMESTIC WELL PUBLIC .DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool e Dia. of Well Excavation <br /> Domestic/private Dri.11ed Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION Contractor &e- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT [] State Work Done <br /> PUMP ❑State Work Done_ r, f, G � ----. <br /> DESTRUCTION OF WELL: Well ,Diameter Approximate Depth <br /> Describe Material and Procedure <br /># I hereby certify that I have prepared this application4and 'that"'thework 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 theJollowing: <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- -asto. become subject to Workman's Compensation <br /> laws of California. " <br /> 1 WILL CALL FOR A GROUT INSPECT P IOR—T GROUTING AND A FINAL INSPECTION. <br /> SIGNED ,� ,� TLE: DATE: <br /> (VRAW PLOT PL ON REVERSE SIDE <br /> FOR DEPARTMENT 48E ONLY <br /> O. PRASE. I <br /> APPLICATION ACCEPTED BY. /.. <br /> DATE 4l�L= <br /> iLADDITIONAL COMMENTS: ' . <br /> PHASE II GROUT INSPECTION PHASE' III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY�� � DATE Z c� <br /> ,EH 1426 Rev. 12-77 1/78 '2M:- _ <br />