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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'FICE USE: 1601 E. Hazelton Ave. , Stockton, <br /> CA 95205 Permrt No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPPERMIT <br /> Date Issued. -;�_?q <br /> ('Complete .`In Triplicate) �. <br /> Application is hereby made to the San Joaquin Local Health District fora permit to .consCt <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 <br /> District. of the San Joaquin Local Heailth <br /> EXACT STREET ADDRESS 19 q <br /> , <br /> Owner's Name — � � CITY/TOWN� <br /> Address' Phone <br /> - _ r <br /> Cit <br /> Contractors Name N Licensees Z 4 4hone r3 q <br /> IS CERTIFICATE 'OF WORKMAN'S COMPENSATIOP! INSURANCE ON FILE WITH-SJLHD? <br /> YES NO'.. . <br /> TYPE OF WORK (Check) : NEW WELL CI DEEPEN QRECONDITION <br /> WELL CHLORINATION Q L ABANDONMENT DEOTHERT�N i <br /> PUMP INSTALLATION PUMP REPAIR C] PUMP REPLACEMENT.Q <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSP OL/SEEPAGE FI—T- OTHER rt <br /> - PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC DOMESTIC WE <br /> `y INTENDED USE TYPE OF-WELL <br /> Industrial- CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Wei Excavation <br /> --Dar�esti.c/private „Drilled Dia, of Well Casing <br /> Domestic/public Driven <br /> „_, I�ri gati on. Gauge of Casing <br /> Gravel Pack Depth of Grout Sea f <br /> ;��athodi,c Protection <br /> __Df sposal 50ttery ± - Typeof Graut�- -- - <br /> .:—Geophysical --- Other Information <br /> € face Seal sta ed <br /> PUMP INSTALLATION: Contrac <br /> Type of _ 'J i <br /> PUMP REPLACEMENT: <br /> Q State Work Done <br /> SUMP REPAIR: O State Work Done <br /> DESTRUCT ION.,.6F W.EL-- Wel T Diameter <br /> - -- --Approximate Depth <br /> Describe Mated a an Procedure <br /> I <br /> hereby, certify that I have prepared this .application- and 'that -ihe work <br /> with San' Joaquin County Ordinances , State Laws., ..and .RulestianU'.Regulati-onswoflthe 'Sanbe _Joa- dinin �LoW <br /> Health- District.`� Home-owne .'or licensed agent's signature certifies the following: q Local <br /> "I certify that in the performance of the work for which this permit is issued,. I shall <br /> not em 7 o an <br /> p Y y person in such manner as to become subject to Workman 's Compensation <br /> laws :of alifornia. " <br /> I WILL CA FOR A UT I'NSPEC IO PRI TO GROUTING AND INAL INSPECTION. <br /> i'IGNED � <br /> TITLE: r <br /> DR L T PL N ON REV S D DATE' <br />',HASE I R DEP RTMEN USE ONLY <br />,PPLICATION ACCEPTED BY ` <br /> DDITIONAL COMMENTS: DATE 3 <br /> PHASE II GROUT INSPECTION PHASE/111 i INSPECTION <br /> NSPECTION BY DATE <br /> H 14 26 Rev. 9/78 INSPECTION BY DATE -.2-- <br />