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& /-USAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE 1601 E. Hazelton .Avk. , Stockton, CA 95205 ,0, Permit No, <br /> Tel ephone:�1(2094) 466-6781 �- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued�_/6 _-� <br /> This Permit Expires 1 Year. From 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 /> ioan:Jn County Ordinance No. 18621and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT ,STREET ADDRESS CITY/TOWN <br /> Owner' s Name Phone <br /> Address::302 .. _ / City _ ... <br /> Contractor's Name Licenseg.04�&2,plS Phone <br /> IS CERT P ' R, 7 ' <br /> I KATE OF WOftKilAtd S CO3IPENSATIO�! INSURANCE ON FILE WITHSJLHD. YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPENd" RECONDITION CD DESTRUCTION M [T�, <br /> WELL CHLDRINATION-❑ WELL 'ABAND'ONMENT'❑' -'OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Tr; <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 <br /> �mestic/private Drilled ` Dia. of' Well Casing <br /> Domestic/public Driven Gauge of Casing �1+ <br /> Irrigation Gravel Pack Depth of Grout Seal ,3p <br /> Cathodic Protection c_-40tary Type of Grout ' <br /> Disposal . Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done , _ <br /> PUMP REPAIR: R 'a ❑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 San 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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE-: -- DATE: . Z ZZ <br /> DRAW PLOT PLTN ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE, <br /> ADDITIONAL COMMENTS : . 9 <br /> PHASE IL GROUT INSPECTION - - PHASE-III- -FINAL INSPECTION <br /> INSPECTION BY DATE -- - 7__ ___, INSPECTION BY ATE J Z <br /> EH _1426 .� Rev.. '12-77-. - __ 1/78 <br />