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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> .- Telephone: (209) 466-6782 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 2 � CITY/TOWN C. <br /> Owner's Name <br /> ZZ 67�il'fu Phone X467_-72]6_3 <br /> Address 3 $ 3 ,�, ?w er City <br /> Contractor's Name (� License#2 r Q C Phone *7)XS— 3�Z <br /> IS CERTIFICATE OF WORKr1AN'S COMPENSATION INSURANCE 0 FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL MI - DEEPEN 0 RECONDITION C] DESTRUCTION <br /> WELL CHLORINATION D WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR[3.- PUMP REPLACEMENT � <br /> DISTANCE TO NEAREST: SEPTIC TANV SEWER LINES. SSP Ore PIT PRIVY p� <br /> SEWAGE DISPOSAL FIELD �/ 30 + CEL/SEEPAGE P1�— OTHER � <br /> PROPERTY LIN <br /> PRIVATE DOMESTIC WELL�._ PUBLIC D MESTIC WE— LE <br /> INTENDED USE TYPE OF.WELL-:=. CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool Dia. of Well Excavation__/_g. <br />� Pomestic/private Drilled D'a. of Well Casing_ <br /> Domestic/public Driven Gauge-of Casing <br /> ��Gravel Pack DQ <br /> Irrigation Depth of Grout Sea a <br /> Cathodic Protection Rotary C Type-of GroutC'P� r.�i <br /> Disposal Ot <br /> Geophysical r Other Information "r <br /> ' <br /> Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump W.P. � <br /> PUMP REPLACEMENT: ❑State Work Done j <br /> PUMP REPAIR: } <br /> C7State Work Done � <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby c rtify that I. Have prepared_this_.application and that the work will be done in accordance, <br /> nn th San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Local <br /> iealth 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 PRI.OR..TMROUTING'�AND A FI-NA-L -INSPECTION.` <br /> iIGNED .T..ITLE,_ 'C -� .. DATE--:]f <br /> DR W PL PLAN ON REVERSE SIDE <br /> 1HASE I F R EPA TMENT SE ONLY <br /> iPPLICATION ACCEPTED BY DATE .?Z 2 <br /> iDDITIONAL .COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY ' DATE INSPECTION BY DATE <br /> H 14 26 Rev. '.9/78 9/78 2M <br />