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SAN JOAQUIN LOCAL;,HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ,,? 0 " <br /> Telephone: '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - ? <br /> This Permit. Ex fres 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 /> :1 and/or install thelwork�lherein described. ?This application is made in ;compliance. with San. <br /> 11 ,oaquin County Ordinance No. 1862 and the Rules -and Regulations of.the, San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS. CITY/TOWN <br /> Owner' s Name Phone�S�—(oQ�1_ <br /> Address . L City -- <br /> Contractor' s Name License3&5j71 Phone <br /> IS CERTIFICATE OF WORM AWS COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 ' *REC,ON.DIjTLON ® DESTRUCTION[j <br /> ,.�..G- -.�-WELL CH,LORI-NATI�QN-B' SIE"L-'Lt—NT-C7—OTH-ER:O <br /> PUMP INSTALLATION [' PUMP REPAIR❑ PUMP REPLACEMENT [3 <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 /> i <br /> INTENDED USE TYPE OF WELL jCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public; Driven Gauge ofCasing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Inf&; ation <br /> t GeophysicalSurfa�e.::,_eal' Installed b <br /> PUMP INSTALLATION: Contractor ` <br /> sTj pe. of ,P`Ump, H.P <br /> — .Y.�...._�_.-- <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: Q State Work Done �. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth- <br /> Describe Materia ari'd Procedure <br /> = I hereby certify that I have preparedlt:htsiapplication and that the work will be done in accordanc <br /> with San Joaquin County Ordinances, St'a � $hws , and Rules and Regulations of the San Joaquin Local <br /> ' Health District. Home owner or licensed .agent' s signature cer'ifies the following: <br /> "I certify that in the performance of tie work for which this permit is issued, I shall <br /> not employ any person in such manner_a�'to become subject to Workman's Compensation <br /> laws of California.0' ` <br /> I WILL CALL FOR T INS TION'.P„R R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 2�" <br /> '-'DR W PLUT PETN ON REVERSE SIDE <br /> FOR DEPART USE ONLY <br /> . PHASE I <br /> ~ APPLICATION ACCEPTED BY DATE z S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> SEH 1426 Rev. 12=77 - _ . <br />