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SAN JOAQUIN LOCAL HEALTH DISTRICT�FFICEE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. :11 - � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7 16 <br /> S This Permit Expires I Year From Date Issued <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 AaCS CITY/TOWN <br /> Owner's Name Phone <br /> Address _ City . i <br /> Contractor's Name L i c e n s ef2a2 V1 Phone_4-2 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YESZ---r NO <br /> TYPE OF WORK (Check) : NEW WELLJM DEEPEN ❑ RECONDITION ❑ DESTRUCTION M <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ m <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—Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /21 <br /> Irrigation Gravel Pack Depth of Grout Seal SO <br /> Cathodic Protection --Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <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 MateTi'al 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 s ect o Workman's Compensation <br /> laws of California. " <br /> I WILL CALL ..FOWA GROUT INSPEC N PRIOR -TO GROUTING ND A F AL - "SP ON. <br /> SIGNED TITLE. DATE: <br /> -RAW PLOT PL N ON REV SIDEI la�l <br /> PHASE I FOR DEPARTMENT U E ONLY <br /> APPLICATION ACCEPTED BYDATE _�"-3-7d' <br /> ADDITIONAL COMMENTS : ••• _•— <br /> PHASE II GROUT INSPECTION PHASE III F-I-NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 1 -� <br />:H 1426 Rev. 12-77 <br /> __ 1 /78 2M <br />