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FFICE USE. ��� w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> J 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 _ d <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> 62— <br /> (Cotpplete _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 /> U p- �'_ D F <br /> EXACT STREET ADI ESS ,� f�,�'o CITY/TOWN_ /P4,0/4./' <br /> Owner's Name tow--- Phone_ 1 <br /> Address S6f .( Ci tY 2Z/22_50A <br /> Contractor' s Name___&_'4d MO M4License#,3` Phone l � <br /> IS. CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES O <br /> TYPE OF WORK (Check) : NEW WELL L 'DEEPEN 0 - RECONDITION [ •DESTRUCTION ,q , <br /> WELL CHLORINATION Q WELL ABANDONMENT ® OTHER 0 9 ' <br /> PUMP INSTALLATION Q PUMP REPAIR L- PUMP REPLACEMENT ] _1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DO ESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF .WELL_, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven t Gauge of Casing a <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ,: Other Information <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> LUMP REPAIR: ❑State Work Done <br /> gESTRUCTION OF WELL: Wel 1 'Diarneter <br /> �- <br /> Describe Material and Procedure Approximate Depth <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 /> Taws of California. " x <br /> I WILL CALLRR A G3QUT .INSPECTIO PRIOR TO GROUTING-AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: •J� <br /> DR W PLQ L N ON REVERSE SIDE <br /> PHASE I F R DEPARTMENT USE ONLY (, <br /> APPLICATION ACCEPTED BY C DATE �` 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION ' <br /> INSPECTION BY PHASE II `INAL INSPECTION <br /> DATE INSPECTION BY Z�4 DAT ,Z <br /> iH 14 26 Rev. 9/78 ' <br /> T Q/ZW 19M <br />