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SAN JOAQUIN LOCAL HEALTH DISTRICT $ <br /> -OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 101 <br /> Telephone: (209) 466-6781 r = r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT bate 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 /> ,'oanuin County Ordinance lxo. 1862 and the Rules and Regulations of the Sari Joaq in Local Health <br /> District. <br /> EXACT STREET ADDRESS S CITY/TOWN --�-y <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name LicenseI29_2423 Phone �lQ <br /> IS CERTIFICATE OF WO KHAN'S rot�IpENS IOII INSURA*SCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL�EEPEN ❑ RECONDITION ❑ DESTRUCTION[� N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER❑ <br /> PUMP INSTALLATION D -PUMP REPAIR❑ 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 SPECIFIC ID'S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> estic/private Drilled Dia. of Well Casing <br /> Dom <br /> estic/public Driven 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- b : <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 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 age s signature rtifies the following: <br /> "I certify that in the performance of the work for which t is permit is issued, I shall <br /> not employ any person in such manner as o become subject orkman's Compensation <br /> laws of California." <br /> I WILL CALL F R A GROUT INSP ON PRIOR TO GRO NG AND A F A I PECT / <br /> SIGNED TIDATE41 p� <br /> (DRAW PLOT PL N REV E SIDE <br /> FOR DEPARtZWFUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 7-7 -` ZF- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY."' DATES <br />-EH _1426 Rev. 1.2-77 1/78 _2MJ. <br />