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s <br /> r• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fFFICE 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 Issued <br /> Complete I n Triplicate) ,. -?t�r- .7 <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 /> ,'oaquin County Ordinance No. 1862 and the Rulesand Regulations of the. San..Joaquin Local Healt, <br /> ,'.Strict. <br /> ACT STREET ADDRESS . CITY/TOWi <br /> Owner --Name- Phone <br /> i <br /> Address_'Z �� C ,. SS�" -- Ci.ty <br /> Contractor's Name License# Phonq (r,Q-3�3�`] <br /> 7S CERTIFICATE OF WORKMAN'S COMIPENSATION I'N'SURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLO. DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ED OTHER ❑ <br /> : ..� PUMP INSTALLATION FPUMP REPAIR❑ PUMP REPLACEMENT <br /> f # <br /> DISTANCE TO NEAREST: . SEPTIC TANK '0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDJ6j CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/_ PUBLIC DOMESTIC -WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> C <br />� Industrial Cable Tool Dia. of Well Excavation )� ' <br /> .Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/publicr Driven Gauge of Casing f <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ____Rotary Type of Grout 9 o w <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed--by41613A , <br />' PUMP INSTALLATION: Contractor -F ` <br /> Type of Pump --� - - - - - H.P. <br /> PUMP REPLACEMENT: ❑ State Work; Done <br /> PUMP REPAIR: t <br /> ❑State Work` Done <br /> DESTRUCTION OF-WELL: ' Wei.l­Diameter v�_. Y~ � 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 fo-r•.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 INSPECTION PRIOR TO GROUTING AND.-A FINAL INSPECTION. <br /> SIGNED TITLE: DAT E:,51,1 ? -9(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a19 <br />' ADDITIONAL COMMENTS: <br /> . PHASE II GROUT INSPECTION- sI. PHASE III -FINAL1NSPECTIOP . <br /> INSPECTION BYDATE INSPECTION BY co DATE <br /> £H 1426 Rev_ 12-77 1 /78 2M <br />