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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> y- <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,�9_,3_:, - <br /> This Permit Expires I 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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS " CITY/TOWN e <br /> Owner's Name Phone <br /> ys- <br /> Address ��'� �e �. City <br /> Contractor's Name 74 L i c e n s e# a Phone_8"36'10�01' <br /> IS CERTIFICATE OF WORKIIAN'S COMPENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES NQ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION ANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT 0 <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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> --- ,.--,-Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _-;'_' �Driven Gauge of Casing W d <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surf ce Seal Installed b <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 Materia an-d 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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ' <br /> SIGNED TITLE: DATE: <br /> fflRW PLOT PLVN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT -USE ONLY <br /> 01 <br /> APPLICATION ACCEPTED BY6�z AG DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE —/1;7` <br /> 12-77' , �, <br />