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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�IEFI�CEUSE: /1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 g_Z.2,d <br /> Telephone: (209) 466-6781 F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-- <br /> This Permit Expires 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �� �j� CITY/TOWN <br /> Owner's Name Phonedq( <br /> Address / C 7 �.���`'— K City <br /> Contractor's Name Licensee Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN IINSURANCE ON FILE WITH SJLHO? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION [,] DESTRUCTION[D <br /> WELL CHLORINATION Q WELL ABANDONMENTED OTHER 0 � <br /> PUMP INSTALLATION 0 PUMP REPAIRf& PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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/publ i c --'-Dri ven 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.P. 7 / <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Wtate Work Done <br /> DESTRUCTION OF WELL: Well Diameter aDroximate Depth <br /> Describe Material ana Procedure <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 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 CALL FOR A GRW IjqSPECTIO&PRIOR TO GROUTING AN A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE' <br />_EH 1426 Ray_ 12-77 � `�G`" 1/78 2M <br />