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SAN JOAQUIN LO7AL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazeltbn- Ave. , Stockton, CA 95205 Permit No. _7 q_-67Z <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT [ aafe'.Issued 6-Z M -71 <br /> This Permit Ex ires 1 Year From Date Issued E4� <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 /> .'oa(iuin County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin Local Healtk"5.j <br /> District.. a3/, 0) <br /> EXACT STREET ADDRESS �,- <br /> �kG� " CITY TOWN w <br /> Owner' s Name Phone -/ <br /> Address_ .. . City <br /> Contractor' s Name License#oZ9d / Phone <br /> IS CERTIFICATE 'OF WORKMAN'S COMPENSATIOi! INSURANCE ON FILE WITH SJLHD? YES NO C <br /> TYPE OF WORK (Check) : NEW WELLN DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , g <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER&)a.1_-149 <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/0rivate Drilled Dia. of Well Casing - <br /> Domestic/public Driven - Gauge 'of Casing ZA10cv <br /> Irrigation __�LGravel Pack Depth of Grout Seal <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other. Other Information a-f <br /> Geophysical Surface Seal Installed by: ��, <br /> PUMP 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 /> Describe Material ana Proce 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 the work for which this permit is issued, Is 11 <br /> not employ any person in such manner as to become subject to Workman's Compensat" <br /> laws of California. " <br /> I WIL CLL FOR A MUT INSPECTION PRIaR TO GROUTING AND A F,4qAL INSPECTION. <br /> SIGNS TITLE: DATE: lP/3 <br /> '(6RAW PLOT KAN ON REVERSE-SIDE) <br /> PHASE I FOR DLFP& T USE ONLY <br /> APPLICATION ACCEPTED BY Xo DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> _6/-Z 7,A, <br /> EH 1426 Rev. 12--77 1/78 2M <br />