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Y� <br /> SAN JOAQUIN 'LOCAL :HEALTH DISTRICT <br /> FQR V <br /> OFFICE USE. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. �- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From ,Date ISs6ed <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct <br /> and/or install the work :herein described: This application .is made in compliance with-San <br /> Joaquin County OrdinanceNo. ,1862' and the Rules and Regulations of the.:.San- Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS C1© 0 � CITY/TOWN <br /> Owner's Name <br /> Phone <br /> C i ty ` <br /> Contractor' s Name- <br /> Address— <br /> Li <br /> �� cense# G 2 Phone 3 6 <br /> .M <br /> IS CERTIFICATE OF WORKPIAN'S C04r4PENSATIO�1'I1,'JSURA"10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check): NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION C1 WELL ABANDONMENT ❑ OTHER ❑ <br /> ,UMP INSTALLATION ❑ PUMP REPAIRS PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �o <br /> .- PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL .L=--1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of _Wel l TCa"s i ng� <br /> Domestic/psi1 i� k Dri ven Gauge oofCasing y -� <br /> . Irrigation �;, Gravel,,P,ack Depth of Grout Sea <br /> Cathodic Protection . Rotary._ .}f Type of Grout s <br /> ' Other Information <br /> Disposal Other _ <br /> Geophysical _ 4 Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor } ' <br /> Type of Pump r H.P - <br /> ` PUMP REPLACEMENT: E]State Work ._Done` + <br /> PUMP REPAIR: 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 accordant+ <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 OR A GROUT�- INSPECT N PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> i�. R W PLOT PLAN' ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f I - <br /> APPLICATION ACCEPTED 8Y; DATE_ <br /> ADDITIONAL COMMENTS: it <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 11. DATE INSPECTION BY DATE 7 <br /> ����� <br /> e'rw l d_7Ci Dow 1 9_77 �11 —_ 1.478 2MI <br />