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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No 7f— .3/ <br /> Telephone: (209) 466-6781 <br /> ed <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issu5�q 7 <br /> (complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons uct <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 /2 G r CITY/TOWN <br /> Owner's Name Phone <br /> Address. / 7- P0 City <br /> Contractor's Name License# Phone <br /> ?S CERTIFICATE OF WO K1AN.'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES NO. <br /> TYPE OF WORK (Check) : NEW WELL U DEEPEN 0 RECONDITION Q DESTRUCTIONED <br /> WELL CHLORINATION d WELL ABANDONMENTE3 OTHERF--3 <br /> PUMP INSTALLATION 0 PUMP REPAIR 0- - PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC 'TANK L EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPUOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WE— U <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> i Industrial fable Tool Dia, of Wel Excavation 10 <br /> Domestic/private Drilled Dia. of Well Casing 17 <br /> Domestic/public Driven Gauge of Casing 2_ <br /> k t/I,rrigation Gravel Pack Depth of Grout Seal MoA1F <br /> Cathodic ,Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP REPAIR: Q State Work Done <br />{ DESTRUCTION OF WELL: Wel-1-0-i-ameter Approximate Depth <br /> Describe Mater a and Procedure <br /> I hereby certify that I 'have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , acid Rules and Regulations of the San Joaquin Local <br /> : Health District. Home owner or licensed agent' s signature certifies the following: <br /> k "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 C FOR ' OUT INSPECTION PRIOR TO GROUTING AND _JINA INSPE VION. <br /> SIGNED TITLE: `� DATE: <br /> ---FDRAW PLOT FLTNT ON REVE SI <br /> F <br /> PHASE I OR DEP MEN USJ- ONLY �A/15 <br /> APPLICATION ACCEPTED BY L �DATE 7 <br /> ,ADDITIONAL COMMENTS: <br /> 11 PHASE II GROUT INSPECTION PHAS I WFIAL - INSP CTION <br /> INSPECTION BY DATE `INSPECTION ..BDATE �a r <br /> EH 14 26 Rev. 9/78 11-1 . 9/78 .2M <br />