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. I <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 [late <br /> it No.? <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT issued <br /> (tomplete , 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' Regula'tions of the Sari Joaquin Local Health I <br /> District. s� S� S'a*° <br /> EXACT STREET ADDRESS CITY/TOWN ,o ,v <br /> Owner's Name Phone 3,P—,251 <br /> Address <br /> City size- <br /> Contractor's NamelPel License# _ Phone 3 <br /> IS CERTIFICATE OF WORKMAN`S COMPENSATION INSURANCE ON FILE <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION Q— PUMP REPAIR[3--- PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK ,v. .SEWER LINES PIT PRIVY <br /> SEWAGE DISP SO E6 FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINES PRIVATPD ESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE.' TYPE'OF .WELL., CONSTRUCTION SPECIFICATIONS .� <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Do <br /> mestic%private Drilled Dia, of Well Casing <br /> 'Domestic/public Driven-- '' Gauge of Casing <br /> -Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other '+ Other Information <br /> Geophysical - Surface Seal Installed by: <br /> PUMP INSTALLATION:- Contractor- ,yr x. � <br /> Type of Pump H.P. <br /> , <br /> PUMP REPLACEMENT: ]State Work Done t , <br /> PUMP REPAIR: ❑State Work Done', <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> If hereby certify that I have prepared this application and that the work will be doneFin accordane� <br /> with San Joaquin County Ordinances , State Lags , and Rules and Regulations oft-he`San Joaquin Local <br /> Health District. dome 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 sh 11 <br /> not' employ any person in such manner; as to become subject to Workm _;s, Co p nsation <br /> laws of. California." k ' <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND VF-I-NASPECTION. <br /> SIGNED <br /> TI-TLE• DATE: .� <br /> - R P(UT- PLAN ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br />[PHASE I <br /> APPLI ATION­ACCEPTED-BY` _ ` /' DATE S� 7GI <br /> ADDITIONAL 'COMMENTS: <br /> PHASE II ROUT INSPECTION i PHASE III 'FINAL ' INSPECTION <br /> INSPECTION BY DATE ' t INSPECTION BY <br /> EHI 14 26 Rev. 9/78 -- DATE S� <br /> 9/78 2M <br />