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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />_.FOR,OFFICE USF-'.if 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit •No.:Zj, 16.a5 <br /> Telephone: .(209) 466-6781 , a= <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7yla-7 <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 /> Joaquin County Ordina'nce •No. -1862 and the Rules and Regulations of the San Joaquin Local- Health <br /> District. <br /> .� CITY/TOWN <br /> EXACT STREET ADDRESS vl0 <br /> Owner's Name Phone <br /> Address City <br /> Contractor's. Name. �v-} Licensee Phone <br /> IS CERTIFICATE OF WOftKt AN'S�6M. ENSAT 0°�j I*SURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL, DEEPEN El RECONDITION C] DESTRUCTION[] <br /> WELL .CHL�ORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMP- INSTALLATION Q 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 SPECIFUATJONS <br /> Industrial s Cable Tool Dia. of Well Excavation_ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 4 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed <br /> { <br /> PUMP INSTALLATION: Contractor r <br /> i Type of Pump H.P. <br /> PUMP REPLACEMENT: , ❑State Work Done <br />, PUMP REPAIR: r ❑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- s-ignature certifies the following: <br /> "I certify that infthe performance of the work for which this permit is issued, I shall <br /> not employ any pers.an"in such manner as to become N`D ' t� to Workman's ;Compensation k, <br /> laws of C lifornia." ' <br /> I WILL CAL FIR A GROUT, INSP ION PRIOR TO GROUTING SP 1 le <br /> .oma <br /> SIGNED TITLE: OATE: 'I' <br /> �DRAW PLT PLKN_ ON REVWE SIDE <br /> t -FOR DEPARTMENT ONLY- .. <br /> PHASE I " <br /> APPLICATION ACCEPTED 8•Y­"� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION TH E III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C • ATE <br /> ` . a �p <br /> i n� r�s.�",. r-. 1/78 2M <br />