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SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> FF06,R�FFICI USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -654 <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6- zP-74 <br /> This Permit. Expires 1-Year From Date Issued <br /> Complete In Triplicate —o <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 /> L'oaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> J i 5 t r i C t. <br /> EXACT STREET ADDRESS r ` ITS/TOWN <br /> Owner's Name A Phone <br /> Address CQ City <br /> Contractor's NameLicense# Phone� ,��� V j <br /> TS CERTIFICATE OF WORKMAN'S COR ENSATItT1 IINSURAINCE MI FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHL RINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVAET DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 5� <br /> Domestic/private Drilled Dia. of Well Casing ,LQ? f <br /> Domestic/public Driven Gauge of Casing_ qaj <br /> _ Irrigation7DF/,U��4-- `Gravel Pack Depth of Grout eal <br /> Cathodic Protection � e Rotary Type of Grout ' <br /> —Disposal - OtherOther Information <br /> Geophysical Surface Seal Installe <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 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 GROU INSPECTION PRI R TO GROUTING AND A F144AL INSPECTION. <br /> SIGNED < TITLE: JeDATE: 1 ZZZ <br /> '(DRAW PL T P& ON REVEZE SID <br /> PHASE I FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 426 R _ J2—9'/ `''1 /5 Se 2 lett J f As a ""!'i1 l 8 Gi:bI <br />