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SAN JOAQUIN LOCAL HEALTH DISTRICT -----�—•-- <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres 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 /> loanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS S^� r p CITY/TOWN 4,n"4�A <br /> Owner' s Name Mates Phone <br /> Address Sa.,.,,, Ci ty <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKM'AN'S COMPENSATIO�J INSURANCE ON FILE WITH S_JLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q RECONDITION ❑ DESTRUCTION10" <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER Q a, <br /> PUMP INSTALLATION Q PUMP REPAIR Q PUMP REPLACEMENT Q L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <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 <br /> Type- of Pump H <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: Q State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter '�` ` App oximate Ue t U�r�C�. <br /> Describe MateriiateProcedure � � 52► � i <br /> C gig, G� <br /> I hereby certify that I have prepared this application 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 Workman's Compensation <br /> laws of California." <br /> I WILL C L FOR A GRO T INSPECTION/PRIOR TOGROUTING AND A FINAL INSPECTION. <br /> SIGNED DATE: <br /> CI (DR-AW PLOT PLAN ON VERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATEA'7z-�� <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY G �� DATE <br /> 1/78 2M <br /> EH 1426 Rev. 12-77 , <br />