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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P±���F�F�ICEUSE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 1 9p <br /> Telephone: (209) 466-6781 <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 /> nn ._.. <br /> EXACT STREET ADDRESS fp� j �"�/� C Of CITY/TOWNStQ 'Tr?ov_,;, <br /> Owner's Name Phonefz� <br /> Address -� p« V <br /> Ci ty7� �� .✓ <br /> Contractor's Name _. License#,14 7 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION .I.NSURAINCE N FILE WITH SJLHD? YES O <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT L OTHER 0 <br /> PUMP INSTALLATION 9G— PUMP REPAIR 0- PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: _ SEPTIC TANK SEWER LINES _fv't PIT PRIVY <br /> SEWAGE DISP 5AL FIELDCESSPOOL/SEEPAGE FIS- OTHER <br /> PROPERTY LINYS PRIVA�ESTIC ELL...34Q_, PUBLIC D ?MMESTIC WELL <br /> INTENDED USE TYPE OF-WELL, NSMa <br /> �IO ' <br /> PECIFICATIONS <br /> Industrial Cable Tool Dia, f ell <br /> v--Domestic/private Drilled Dia. f Well Casing <br /> ._Domestic/public Driven �ju of Casing <br /> Irrigation Gravel Pack C ( th of Grout Sea <br />—Cathodic Protection Rotary, �1 Type of Grout <br /> Disposal Qth Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> cs <br /> =gnaType of Pump .P. <br /> PUMP REPLACEMENT: Q State Work Do j <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <br /> p <br /> I hereby certify that i have prepared this application and that the work will be done in accordance, <br /> with San Joaquin CourTty Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local . <br /> Health District. Home owner or litens-ed-a-gertt-`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-FI-FAL INSPECTION. <br /> SIGNED TITLE.: DATE: 3zxz <br /> D W P L N ON REVERSESIDEL <br /> 1HASE I FO DEPARTMENT, USE ONLY <br /> PPS LICATION ACCEPTED BY DATE 11.217Z <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> 7H 14 26 Rev. 9/78 9/78 2M <br />