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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.? - . 1 <br /> Telephone: (209) 466-6781 <br /> 4-APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued • <br /> E <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. 1.862 and the Rules and' Regulations of the San Joaquin Local Health j <br /> District. <br /> EXACT -STREET ADDRESS CITY/TOWN -4 , <br /> Owner's Name L/ Phone46-11 <br /> Address �' City <br /> Contractor's Name �~ License# hone fz <br /> IS CERTIFICATE OF WnR MAid'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION Q DESTRUCTION <br /> WELL CHLORINATION D WELL ABANDONMENT 0 OTHER 0 � I <br /> PUMP INSTALLATION M PUMP REPAIR❑- PUMP REPLACEMENT [a <br /> DISTANCE TO NEAREST: SEPTIC TAMC_flD�'1�SEI ER LINES a6 J?-- PIT PRIVY <br /> SEWAGE DISP SO AL FIELD C SSP OL/SEEPAGE PIS OTHER <br /> PROPERTY LINE - PRIVATE DO ESTIC WELL PUBLIC DOMESTIC WELL — <br /> INT'ENDEQ't1SE " 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 <br /> f�Irrigation' Gravel,. Pack Depth of Grout Sea /yoA14 <br /> Cathodic Protection Rotary Type'of Grout <br /> Disposal Other Other Information " <br /> Geophysical Surface-Seal -Insta• ed y: <br /> PUMP INSTALLATION: Contradt&_ 4v-�,JAefl -of Pump v 6 �vYc - _ H.P. <br /> PUMP REPLACEMENT: Q State-Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth•.. =_ F <br /> Describe Materia and Procedure <br /> fir' <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 /> "ealth 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 /> ;.-'Knot employ o <br /> p y an y person in such manner as to become subject to Workman's Compensati-on <br /> : laws of California .Is <br />� I WELL C FOR A G INSPE TION PRIOR TO GROUTING AND A FIN#L IN ECTION. <br /> E SIGNED TITLE: DATE: <br /> W PLT PLAN ON REVERSE SIDE <br /> PHASE I F R DEPARTME USE ON <br />,TP—PLICATION ACCEPTED BY DATE <br />,ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE — � <br /> EH 14 26 Rev.. 9/78 �' 9%78 2M <br />