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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -F10E USE: ` 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.78:/b 94_ <br /> Telephone: (209) 466-6781 <br /> RPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuef -- <br /> This Permit Expires 1 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 /> 1'oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ( •� I CITY/TOWN e <br /> Owner' s Name o ry aY Phone <br /> Address city,T,r-txcy _ <br /> Contractor's Name &A. License#)g15oo- Phone — 13 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"! IIISURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLX DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION)4 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <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 <br /> _Domestic/private 11 ed Dia. of Well Casing <br /> 4 Domestic/public Driven Gauge of Casing S cNN 9 0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout C� 4_ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION: tor—y--t—,-A XC' <br /> Type of Pump L- H.P. <br /> PUMP REPLACEMENT: 71State 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 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 GRO INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE : DATE: <br /> ttDRAW PLOT PLAN ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -- � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINak INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />,EH 1426 Rev. 12-77 mar ► 7 2M <br />