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R SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No..2:±-/9 9„ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued '/7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a-peemit 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' Regdlations of the San Joaquin' Local Health <br /> District. <br /> EXACT STREET ADDRESS �� &j rt-Pg au/i'/ # CITY/TOWNS <br /> Owner's Name , M, /(lA r Phone 63 <br /> Address—3 Z 35 '` Moq Ci ty T� /r-%27 <br /> Contractor's Name ,/Ll, icy i/ License#�� Phone2F <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE 4. FILE WITH-SJLHD? YES N0. <br /> TYPE OF WORK (Check) : NEW WELL 93-'- DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION n WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR E, - RUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANKSP'_± SEWER LINES PIT PIT PRIVY <br /> SEWAGE DISP SAL IELD /J-0 CESSPOOL/SEEPAGE PIr— OTHER <br /> PROPERTY LINg 5 PRIVATE DOMESTIC WELL PUBLIC—DOMESTIC _RELL <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool D,"a. of Wel Excavation <br /> Domestic/private Drilled ia. of Well Casin <br /> Domestic/public Driven Gauge of Casing ��� <br /> Irrigation f---Gravel\P k Depth of Grout Sea <br /> _ Cathodic Protection Rota .y Type of Grout j' <br /> Disposal5 0 e Other Informat7on <br /> Geophysical Surface Seal Installed d s� <br /> PUMP INSTALLATION: Contrac r . <br /> Type of p . H.P. <br /> PUMP REPLACEMENT: ❑State Mork Done{ <br />' PUMP REPAIR: O 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 Sari 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 GRO T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> D P T L ON REVERS'E SIDE <br /> PRASE I FOR <br /> DEP4RTMENT ONLY <br /> PP�LI'CATION ACCEPTED BY DATE � <br /> ADDITIONAL COMMENTS: <br /> 3P I GROUT INSPECT ON INSPHASE FINAL INSPECTION <br /> INSPECTION BY DATE - '�'� • ----- <br /> PECTION BY DATE <br /> EN 14 26 Rev. 8 9/78 2M <br />