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�- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f FFICE USE: 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit No. F79- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT a.. 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 Ordinanc No.11862 and the Rules and Regula io s o the San Joaquin Local Health <br /> District. <br /> E EXACT STREET ADDRES <br /> i�� TY/TOWN <br /> Owner's Name S .00Phone <br /> Address u ' c� City <br /> Contractor's Name License#/ Phone v <br /> ]d <br /> IS CERTIFICATE OF WORKMAN'S CO"i SA IO'! TINSURANCE ON FILE 41ITFf SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN C! RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER ❑ <br /> PUMP INSTALLATION OR PUMP REPAIR❑ PUMP REPLACEMENT Q <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 - j <br /> ' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing # <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 'Rotary , Type of Grout j <br /> - Disposal Other Other Information <br /> Geophysical Surface Seal Installed b .E <br /> E PUMP INSTALLATION: Contractorzz 2 5z + t �.•. _, <br /> Type of Pump06AW --Jrlleg All H.P. _ e � <br />. PUMP REPLACEMENT: MState Work Done <br /> PUMP �: `:, (State Work Done..' ,/ <br /> DESTRUCTION OF WELL : Well Diameter V 01 <br /> 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 accordanc <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaqu ri_•Local <br /> Health District. Home owner or licensed agent' s signature certifies the following : � <br /> Certify that in the performance of the work for which this permit is issued, I' shall <br /> H T ti <br /> not employ any person in such manner as to become subject to Workman's 4 <br /> Compensation _ _ , 1 , <br /> laws of California . " <br />; I' WILL CALL' FOR A GROUT INSPECTION P I JJ GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTLE : <br /> 1 DATE: l <br /> JDPW L REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , ,. DATE 7//,?-Z <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHA E I ANAL INSPECTION q <br /> INSPECTION BY DATE INSPECTION BY ff� DATE %:: 6'7 <br /> LH 14 26 Rev. 9173 5/79 2M.r'-• <br />