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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 :Date <br /> t No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Issued< -'7 <br /> (Cow Tete 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, AR 3 <br /> EXACT STREET ADDRESS A CITY/TOWN <br /> Owner's Name Kl ` 1 ` `�� �, '— Phone'�� <br /> Address <br /> 'ea- City ^,el � <br /> Contractor's Nam e �� I` �' . v jSyLicensedy;3.;ke,-Vhone 3 `! " 7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJIHD? YES Lam' NO <br /> TYPE OF WORK (Check) : NEW WELL W-' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT O OTHER 0 �1 <br /> PUMP INSTALLATION 23' PUMP REPAIR[D PUMP REPLACEMENT I] <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES/ _3 PIT PRIVY <br /> SEWAGE DISP SEAL FFIELD CESSP OL/SEEPAGE P OTHER j <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC D MESTIC A L� L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria Cable Tool Dia. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing 4— <br /> Domestic/public Driven Gauge of Casing lrjge <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection �Rotary Type of Grout � <br /> Disposal Other Other Information <br /> Geophysical ,{ Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor O_P_e; �� �Z- S_ � <br /> e-o , H. . 7 <br /> PUMP REPLACEMENT: Type of Pump_ <br /> []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an roc- ure <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED. TITLE DATE: <br /> PLOT FLTN- ON REVERSE SIDE)- <br /> PHASE <br /> IDE PHASE I R E MENT SE ON <br /> APPLI TION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE - � <br /> PHASE II GROUT INSPECTIO / PHASE III FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY DATE <br /> Eh 74 26 Rev. 9/78 9/78 2M <br />