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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton­Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: ; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> I Thais Permit Exx ires 1 Year From Date ,Issued <br /> kComplete In Triplicate <br />' Application is hereby made totheSan. Joaquin Local Health District fora permit to construct <br /> and/or install°.the work herei described, This application is made-in compliance with San <br /> ,oaquin County Ordinance No. +1862 and the Rules arid -Regulations of the San Joaquin Loca-1 Health <br /> District. <br /> EXACT STREET ADDRESS <br /> `f-7_ CITY/TOWN �� �.. <br /> Owner's Name S' - <br /> Phone <br /> Address i — <br /> o City !r <br /> Contractor's Name <br /> w <br /> Licensees Phone l -- <br /> IS CERTIFICATE OF WORKMAN'S COMPEL SA�, �wURA"CE ON FILE WITH SJLHD? YES V NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP,,INSTALLATION ❑ PUMP REPAIR G9— PUMP REPLACEMENT [� W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .0 <br /> SEWAGEDISPOSAL FIELD y CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL CSI <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private a - Drilled Dia. of Well -Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal 1 Other Other Information - <br /> Geophysical I Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: 17 State. rk Done <br /> PUMP REPAIR: 6a <br /> f�IState Work. Done <br /> DESTRUCTION OF WELL: well Diameter Approximate Depth <br /> Describe Materia an , 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"Orden-&ore—s;-S'tate 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-i-n--s-uch;manner-as to become subject to Workman 's Compensation <br /> --laws of Cal ifornia."w.---- --f - - _ - - - s _ - .- <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO.GROUTING,AND . FINAL- INSPECTION. <br /> 3.I.GNED TITLE• _ -DATE:.._, 1-3_ �.' <br /> s DR W PLOT PLTN ON RE10ERSE SIDE k <br />'RASE I FOR DEPARTMENT USE ONLY <br /> FPPLICATION ACCEPTED BY DATE 3 --z 11 <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INS',PECTION ' PHASE Il AL INSPECTION <br /> NSPECTION BY DATEINSPECTION BY DATE 16 <br /> Y1426 Rev. 12-77 _ _ <br />