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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LEOFFICE USE: 1601 E. Hazelton Ave. , Stockton', CA 95205 Permit No. <br /> s-ti- Telephone: (209) 466-6781 _ <br /> -_ Date IssueW06-7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete 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 1 344 3c ,&. 7TO . ,sl )A-o.d CITY/TOWN <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name AV License# c/77&7-Phone <br /> f <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES -,,a NO. <br /> TYPE OF WORK (Check) : NEW WELD DEEPEN 0 RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR 0- NMP REPLACEMENT ❑ W <br /> DISTANCE TO NEAREST: SEPTIC TANK_�_d ax SEWER LINES ,00-+ PIT PRIVY--c7' _ <br /> SEWAGE DISPSO AL FIELD_!oa_-v� CESSPOOL/SEEPAGE PI-T_� OTHER -0- <br /> PROPERTY <br /> THER -e- <br /> PROPERTY LINEdjv'l'RIVATE DOMESTIC WELL�_ PUBLIC D MESTIC WE =-e- <br /> INTENDED USE TYPE OF-WELL.. CONSTRUCTION SPECIFICATI5INS ` <br /> Industrial Cable Tool Dia. of Wel Excavation <br /> Domestic/private _Drilled Dia. of Well Casing %• <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation _ X_Gravel Pack Depth of Grout Sea �—� <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal'-ed b <br /> JA <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H, <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth. <br /> Describe Materia ana Proce ure <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 INSPEC ION PRIOR TO GROUTING AND A FINAL INSPECTION. ` <br /> SIGNED TITLE: DATE: • - <br /> (DRAWL N ON REVERSE SIDE <br /> PHASE I <br /> R DEP TMENT USE ONLY <br /> PPLIC TION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PH E II GROUT INSPECTION PHASE III 'FINAL INSPECTION <br /> INSPECTION BY �i DATE-= INSPECTION BY �' l' . DATE <br /> EH i4 26 Rev: 9/78 --- - --- -- - - 9178 <br />