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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFOR FEICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.-!Z$-//, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedJa_��-�$ <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 Ila X I tX C CITY/TOW c-,�, <br /> Owner's Name n Phone <br /> Address re City <br /> Contractor's Name License#] 4 'D o Phone 5 <br /> IS CERTIFICATE OF-WORKMAN'S COMPENSATIOIN I'NSURAINCE ON FILE WITH SJLHD? YES V-' NO <br /> TYPE OF WORK (Check) : NEW WELL[A- DEEPEN 0 RECONDITION ❑ DESTRUCTION C] W <br /> WELL CHLORINATION C1 WELL ABANDONMENT 0 OTHER 0 r <br /> PUMP INSTALLATION F�g PUMP REPAIRED 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/public Driven Gauge of Casing Sr _ C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout C,Q.�,,�` <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor C—z . <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 GROUT INSPECTION PRIOR TP GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> R W PLOT PL N ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL jNSPECTION. <br /> INSPECTION BY DATE INSPECTION BY ,DATE_ <br />-EH 1426 ge-v-- 12-.77 --_ - 1/78 <br />