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SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> FFICE USE: 1601 E. Hazel�tonike. �'Stockton, CA 95205 Permit No. 31. <br /> Telephone: ' (209) 466-6781 pate Issued �7 <br /> / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> t <br /> (Eomplete:'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 /> . <br /> Districtr �, � r <br /> EXACT STREET ADDRESS ,wry . CITY/TOWN <br /> Owner's Name Phone <br /> Address i .: <br /> - ti. - City • r. <br /> Contractor's Name .. E _,., . Ae,.: : �.:.�. r' - Li cense# , r Phone. r-,,. <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NSW WELLE=] DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ �: <br /> WELL CHLORINATION ❑ ABANDONMENT ❑ OTHER Q <br /> SWELL • --� <br /> PUMP INSTALLATION 0 1PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ,: SEWER LINES PIT PRIVY <br /> - <br /> SEWAGE DISPOSAL FIELD°:— CESSPOOL/SEEPAGE FI—T_ OTHER <br /> PROPERTY LINE{ - PRIVATE DOMESTIC WELL_: PUBLIC DOMESTIC WELL <br /> INTENDED USE .,..Y". fi TYPE OF WELL ; CONSTRUCTION SPECIFICATIONS <br /> Industrial '' Cable Tool° Dia, of Wel Excavationk -� _ <br /> ..: Domestic/private Drilled Dia. of Well Casing_ _ <br /> Domestic/public Driven Gauge of Casing . . }�.: .. <br /> Irrigation Gravel Pack Depth of Grout Sea t"-• <br /> Cathodic Protection Rotary ;; Type of Grout . <br /> Disposal Other Other Information <br /> Geophysical „ Surface Seal Insta ed <br /> PIMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ;.[]State Work Done <br /> PUMP REPAIR: ❑State Work-Done <br /> DESTRUCTION OF WELL: Well Diameter . Approximate-Depth <br /> T Describe Materia an voce ure <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 theiwork 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 /> rI WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED . : ,� �v, w`� TITLE: DATEY _,. -- <br /> RAW PIOT PEW ON REVERSE SIDE) <br /> FOR REP .RTMENT U 0 <br /> w PHASE Ir <br /> PPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: tj <br /> . PHASE II GROUT INSPECTION PHASE III 'FINAL INSPECTION <br /> INSPECTION BY DATE " INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 9 8` <br />