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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: w 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit -No._ ,-7-1-1011 <br /> Telephone: (209) 466-6781 `7 6 <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Date Issued <br /> This Permit 'Ex ires 1 Year From Date Issued/7 <br /> / Complete In Trip irate ' <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. l O <br /> '77 <br /> EXACT STREET ADDRESS <br /> [/�_ i CITY/TOWN -- <br /> Owner' s Name Phone _ <br /> Address City <br /> Contractor's Name --� <br /> L i c e n s e# Phone� Z l 63 <br /> IS CERTIFICATE OF WOR IAN'S COMPENSA7GIM INSURAINCE ON FILE WITH SJLHD? YES � NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION[y <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER❑ ' <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC WANK 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 SPECIFIC T NS <br /> Industrial Cable Tool Dia. of Well Excavation • <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ther Other Information <br /> Geophysical Surface Seal Instal ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc( <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 permit is issued, I shall <br /> not employ any person in such manner as to beco subject to WDrkman's Compensation <br /> laws of Cal 'fornia." <br /> I WILL CALL OVA GROUT INSPECTIW PRIOR TO GROUTING IN E IO . <br /> SIGNED TITLE: E:C� <br /> -TDRAW PLOT PLIM ON REVS IDE <br /> FOR DEPARTMENT USr ONLY <br /> PHASE IDAT£� 7� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIN L INSPECTION <br /> INSPECTION BY DATE �'-- --��' INSPECTIaN BY , PATE <br /> EH 1426 Rev. 12-77 __ 1/78 QLAM <br />