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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> P�F�FICEE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2g—Jzk.4,9 <br /> Telephone: (20) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /o <br /> This Permit"Ex ires i Year From Date Issued ' <br /> Complete Ira Triplicate <br /> Application is hereby made to the San Joaquin L6cal 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. 11862 and t Rules and Regulations of the San Joaquin L cal Health <br /> District. 09C�oS1' <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name = R' Phone <br /> Address CA06II& 5 City <br /> Contractor's Name f bA License# - Phone 0�,5-L <br /> IS CERTIFICATE OF W04KMAti'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES tip <br /> TYPE OF WORK (Check) : NEW WELLM DEEPEN 0 RECONDITION [] DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT Q . <br /> DISTANCE TO NEAREST: SEPTIC TANK d�C 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 SPECIFI A IONS <br /> Industrial Cable Tool ia.' of Well- Excavation <br /> Domestic/private Drilled Dia. of, Stell• Casing <br /> omestic/public Driven Gaugeof Casing <br /> Irrigation Gravel Pack Depth' <br /> of Grout Seal <br /> Cathodic Protection Rotary Type of Grout A <br /> ZZA <br /> Disposal Other Other Information ONJ <br /> Geophysical Surface Seal Installed !?I: <br /> PUMP INSTALLATION: Contractor <br /> .Type .of Pump. H.P. <br /> PUMPREPLACEMENT: p State Work Done 43r <br /> PUMP REPAIR: QState Work one <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r _ <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 6r licen d agent's signature certifies the following: <br /> "I certify that in the perfornia f 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 C FOR A T INSPEqON PRIOR TO GROUTING AND,,AFINAL INSPW TION. <br /> SIGNED TITLE: DATE: fO '-7r <br /> DR W PL T PL N ON REVERSE SI E <br /> PHASE I F R DEPARTMENT USE ONLY <br /> JAPACCEPTED BY DATE 0—PLICATION d <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT IN PHASE I-II FINAL IN 'CTION <br /> INSPECTION BY DATE INSPECTION BY. 4 DATE <br /> EH 1426 Rev_ 12-77 <br />