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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF^ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95206 Permit <br /> Y Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ 3-7 <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 4 051) Cp cs/Z # 7 CITY/TOWN <br /> Owner's Name G M. G t vc c-A .P K,• Phone_ — <br /> Address city' <br /> Contractor's Name do License#o't DPhone � 3Z <br /> I5 CERTIFICATE OF WORKMAN'S COMPENSATION INSURAMCE ON FILE WITH'SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL C5�-- DEEPEN ❑ RECONDITION DESTRUCTION[� <br /> WELL CHLORINATION D WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑"_ RUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK Q'-J- SEWER LINES SU rfi PIT PRIVY <br /> SEWAGE DISPOSAL IELD160, CESSP L/SEEPAGE PIT OTHER <br /> PROPERTY LINE/, PRIVATE DOMESTIC WELL_1 D PUBLIC D MESTIC WEEL <br /> INTENDED USE TYPE OF WELL., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well ExcavationZ O <br /> r==Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing P V C- <br /> Irrigation —L.—.Gravel Pack Depth of Grout Sea <br /> Cathodic Protection ,e—Rotary -- .. , Type of Grout <br /> Disposal Other then Information <br /> Geophysical urface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. <br /> PUMP REPLACEMENT: State Work one <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. _ Approximate Depth <br /> Describe Materia 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 Locala <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 C#LFOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. E <br /> SIGNED TITLE: DATE: 3 , <br /> D L T N ON REV RSE SIDE <br /> PHASE I <br /> R DEP TMEN USE ONLY <br /> ONLY <br /> TION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS.- <br /> PH <br /> OMMENTS:PH SEI GROUT INSPECT ON PHASE III FINAL. INSKCTION <br /> INSPECTION BY_ DATE INSPECTION BY DATE <br />£H 14 26 Rev. 8 - - - 9178 2M _ <br />