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A '_.��1 <br /> �r <br /> ..*04 SAN-JOAQUINLOCAL HEALTH DISTRICT <br /> FFI.CE USE: 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No. 7 - f <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued "7- f a-- 7b ' <br /> This Permit <br /> Expires I Year From Date Issued <br /> Complete In Tr.,i pl i tate <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 Sane <br /> Joaquin County Ordinancea,No. 1862 and the Rules and Regulations of the. San .Joaquin Local Health <br /> District.._ <br /> EXACT STREET ADDRESS // a d �j, f CITY/TOWN <br /> Owner's Name Phone_ ' , f-. 7 <br /> Address 7 I City <br /> Contractor' s Name License# Ca 3 Phone f=a 3 <br /> IS tCERTIFICATE OF WORKMAN'S COIAPENSATIOI! INSURAIdCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL.M DEEPEN [j RECONDITION Q DESTRUCTION F1 � <br /> WELL CHLORINATION Ct WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION IR PUMP REPAIR❑ 1 PUMP REPLACEMENT Q p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Va/✓6 00. S <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 /p <br /> A Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publ i c Driven Gauge of -Cast ng <br /> Irrigation Gravel Pack Depth of -Grout Seal <br /> Cathodic Protection =Rotary Type of Grout <br /> y "-Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP- REPLACEMENT: ❑ State Work Done # <br /> PUMP REPAIR: QState Work Done t <br /> - f <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 accordancd <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 ceriti-fies the following: <br /> "I certify that in the performance, of;th'6-wo_rk for which this permit is issued, I shall ,JI . <br /> not employ�'ariy person tri"such manner as to become cubject';to Workman's Compensation - " <br /> : laws of California. i <br /> I WILL CAL OR A GROUT NSPECTION RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: --� <br /> PLOT PLAN ON REVERSES E +i <br /> ji <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ?- <br /> ADDITIONAL COMMENTS: Z, �— <br />�� PHASE II GROUT INSPECTION _ PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 G <br /> EH 1426 Rev. 12-77 - 1/78 2M <br />