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m� SAN' JOAQUIN. LOCAL HEALTH DISTRICT .. <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _ 3 <br /> Telephone: (209)'h466-6781 <br /> 'APPLICATION .FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,g <br /> This Permit: Ex <br /> :: Expires I Year- From Date Issued W <br /> , . F ;Complete In Triplicate <br /> Application is hereby made to' the San Joaquin Local Health Distr.ict .for.,,a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San <br /> ,oaQuin County Gr finance No. . 1862 and the Rules and Regulations of the San Joaquin Local Health CA <br /> District. G <br /> EXACT :STREET ADDRESS <br /> � . a'� �'[G .. G- CITY/TOwf� 3 <br /> Owner' s Name Phone <br /> Address p pity <br /> F Contractor's Nam Licenseesphone <br /> �� - - .-.. <br /> IS 'CERTIFICATE OF WORKMAN'S COM NS TION INSURANCE ON FILE WITH SJLHD? YES NO <br />' TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ "RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMA REPAIR❑ PUMP REPLACEMENT <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> .Disposal.. Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: Contractor <br /> -Type of Pump .JH.P. <br /> PUMP REPLACEMENT: [�2 State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter k <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 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. PE TIO R TO GROUTING ,AND A FINAL INSPECTION. <br /> SIGNE TITLE: DATE: Af <br /> D W PLOT N ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY „z ,:� DATE Z�' <br /> ADDITIONAL COMMENTS: <br /> PHASEROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Q 7 <br /> EH 1426 Rev. 12-77 <br /> '� '-- <br />