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FFI E USE: 1601 <br /> 160] SH <br /> ANJO ' <br /> AQUIN LOCAL HEALTH DISTRICT <br /> an Ave. , Stockton, CA 95205 Permit No. 7 z 1g,v <br /> Telephone: (209)6466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Date Issued _:�—%7 1 <br /> (tom�plete 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 CITY/TOkfN <br /> ,Owner's Name _ t <br /> Phone <br /> .Address !% <br /> +Contractor's Nam ' License# thane - <br /> IS CERTIFICATE OF WORKS?A�J'S 0"?PENSATION INSURANCE. ON FILE WITH SJLHD? YES 0 <br /> :TYPE OF-WORK (Check) : NEW WELL 0 DEEPEN 0'_ RECONDITION ®� DESTRUCTION[] <br /> WELL CHLORINATION 0 -WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION JM PUMP REPAIR 0 PUMP REPLACEMENT qr I <br /> LISTANCE TO NEAREST: :- -SEPTIC' TANK SEWER LINES.. ,- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industria�� CONSTRUCTION SPECIFICATIONS . � <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ._Irrigation Gravel Pack <br /> Cathodic Protection Rotary, _ Tepth of Grout Sea <br /> -Type of_Grout <br /> Disposal � ��„._. . . <br /> Other Other Information <br /> —­ Geophysical <br /> Surface Seal Inst—a—ed—by. # <br /> LUMP INSTALLATION: Contractor -. . <br /> Type of Pump <br /> k H.P. <br /> PUMP �0 State Work Done Aft <br /> . .. . <br /> PUMP REPAIR: (]State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter <br /> DescribeMaterial and Procedure Approximate Depth <br /> I hereby certify that I haveP <br /> P�re ared this application and that the'work will be done 'in accordancee <br /> with San Joaquin County Ordinances, State Laws , Rules._and ReguTatians of the- San Joaquin Local <br /> Health-District dome owner or 'licensed agent' s signature certifies the following: <br /> "I-certify that in the per.formancewof--the •work4for 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 GR .UT INSPEC ON-PR T R TO OUTING-AND A'FINAL INSPECTION. <br /> SIGNE, <br /> TITLE: DATE: <br /> PL SON REVERSE SIDE <br />?HASE Ir- FOR D ARTMENT USE 0 LY <br /> PPS LICATION ACCEPTED -BY ,� <br /> 0DITIONAL COMMENTS: , `�'`` DATE 3 le7191 <br /> PHASE II GROUT INSPECTION <br />'NSPECTION BYDATE PHASE II INAL INSPECTION ' <br />'H 14 26 Rev. 9/78 INSPECTION BY DATE <br />