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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFI E USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 =Issue . <br /> Telephone: (209)466=6781APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (eomplete.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 Rut <br /> District. s and Regulations of .the San Joaquin Local Health, <br /> EXACT STREET ADDRES CIT Y/TO WN�d 0(-'70- <br /> Owner's Name <br /> Address Phone O <br /> -City ..' .:j <br /> Contractor's Name_ License# �3 )3Phon i <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"fCE ON^'FILE WITH SJLHD? YES✓ NO <br /> TYPE OF. WORK (Check) : NEW WELL❑ DEEPEN❑ RECONDITION [] DESTRUCTION❑_ . ,_ J <br /> WELL.CHLORINATION D WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION C] _.PUMP-.REPAIR©..._PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> " 'SEWAGE DIS POS —LFIELD CESSP OL/SEEPAGE-PIT— OTHER O <br /> PROPERTY LINE - PRIVATE D—OT�1ESTIC WELL PUBLIU-WESTIC WE <br /> ! - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> In estic/ -I- <br /> CONSTRUCTION a Tool Dia. of <br /> Well Excavation. <br /> Domestic/private Drilled Dia. of Well CasingDell <br /> Domestic/public Driven Gauge of Casing <br /> � Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection :,..Rotary' r, Type of,Grout <br /> Disposal Geophysical Other v'' * ', Other. Information <br /> Surface Seal Installed <br /> PUMP INSTALLATION: . Contractor - - - <br /> Type of Pump H <br /> PUMP REPLACEMENT: NIState Work Done <br /> 'UMP REPAIR: ' [:]State Work Done 9 � <br /> )EST CUR I7)EST CUR ON�OF WELL? Well Dia eter <br /> Describe Mater an rote ure Approximate Depth <br /> a <br /> t <br /> hereby certify that I have prepared this application and that the work will be done "in accordano <br /> "ith San Joaquin •County Ordinances, State Laws, and Rules and Regulations. of the San-Joaquin-Local <br /> ealth District.- .Home owner or licensed agent's siwgnature certifies the following: <br /> 11 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 T <br /> laws of California." <br /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. - J <br /> [GNED <br /> DR � T�L� ONTREV <br /> ERSE 0 ) DATE 6 /2 <br /> IASE I F R D P TM USE ONLY <br /> 'P ATION ACCEPTED BY <br /> 'D*—ONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION r <br /> iPECTION By I DATE PHAS III " NAL INSPECTION <br /> 14 2.6 Rev. 9/78 " -- INSPECTION BY DATE <br /> _. - -- 9j78._•.- 2M <br />