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SAN JOAQUIN LOCAL :HEALTH DISTRICT <br /> rT 1601 E. Hazelton Ave Stockton, CA 95205 Permit No. >Z_i_�_c� _ <br /> FOR Fc _CE USE: <br /> Telephone: (209) 466y6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued_±_ <br /> This Permit. Ex ices 1, Year From. Date. lssued <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 /> Joaquin County Ordinance No. 1862 and the Rules -and -Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS G CITY/TOWN <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Li cense Phone <br /> IS CERTIFICATE OF WORK4iAN'S CO`1PENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WEL -DEEP EN-O.— . RECONDITION [� .._ DESTRU.CTION.� <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 - <br /> PUMP. INSTALLATION p PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK Yor SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,,,, <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 'W'ELL- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Id <br /> Domestic/private Drilled Dia. of Well Casing zz <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal c5`v <br /> Cathodic Protection Rotary `Type of Grout l�..rl�„r <br /> Disposal Other Other `Ii f-ormati-on <br /> Geophysical ., Surface Seal "Installed by: <br /> PUMP INSTALLATION: Contractor } <br /> L Type of Pump ; H.P. <br /> I <br /> PUMP REPLACEMENT: []State Work Done _ A <br /> PUMP REPAIR: ❑State .Work Dane <br /> DESTRUCTION OF WELL: Well Diameter -ApproFximate -Depth <br /> l Describe Material and Proce ure <br /> I hereby certify that..I .have-prepare.d. this appl..i.cation�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 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 Workn.'rs,�Compensation <br /> laws of California." <br /> I WILL CA FOR A OUT I SPECTI N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: = <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYL4�� Z�LDAT Ev2 -7, _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 7­/i'--Zd' INSPECTION BY DATE/!V '�L7� <br /> r" 11199 Poi, 17-77 - - - 1./78 -2M <br />