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C4�PLto SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> FF CE.A. <br /> 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 74 - 675 <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> (Complete In Triplicate`).' = <br /> Application is hereby made to the San Joaquin Local Health ..District fora permit to construct 1 <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1862 and the les and Regulations of the San Joaquin Local Health <br /> District. OGk <br /> EXACT­STREET ADDRESS 3L d CITY/TOWN <br /> Owner's Name tin P - Phone <br /> Address o <br /> C-i ty� .. ,..,;. <br /> Contractor's Nam w, License# !, -72,�one �. 7--e&1 <br /> IS CERTIFICATE OF WORKMAN'S CnM1 N TION INSURANCE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION 0 DESTRUCTIONIn <br /> WELL CHLORINATION C3 WELL ABANDONMENT 0 . OTHER 0 <br /> PUMP INSTALLATION•F PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PIT OTHER 0 <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 <br /> _-Irrigation Gravel Pack Depth of Grout Se—aT - <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ` Other Other Information <br /> Geophysical - Surface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP- 59State Work Done <br /> DESTRUCTION OF WELL: Well Diameter proximate Depth <br /> Describe Material and Procedure <br /> 1 -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 Joaqui-n 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 /> k laws of California. Y, <br /> I WILL <br /> CALL_FOR A GROUT INSPECT ON PRIAR TO GROUTING AND A"FINAL INSPECTION. w. <br /> SIGNE "r ITLE: - DATE: <br /> PLOT P ON REVERSE SIDE <br /> ' OR DEPARTMENT U ONLY <br /> PHASE I . A <br /> P�PLICATION ACCEPTED BY--, DAT E1-9-ADDITIONAL COMMENTS: ,y <br /> 17 7 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE. <br /> 'INSPECTION BY- DATE <br /> Eli 14 26 Rev. 9/78cCA7 n A 13" <br />