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r- a W SAN JOAQUIN LOCAL HEALTH DISTRICT <br />,--FQR OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, CA 95205 Permit No.7 i?-_ jJS <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued g- <br /> This Permit-Expires 1 Year From Date .Issued <br /> Complete 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 /> ,oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner' s NamePhone 62 27141- <br /> Address— <br /> 7/¢Address SSS''' L- City Ise-A10-1 . <br /> Contractor' s Name Z—? ,v Li cense# !U Phone l�3f4 <br /> TS CERTIFICATE OF WORKMAN'S COIMPENSATIO"! INSL'RAINCE ON FILE WITS! SJLHD? YES X NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPENC--] _RECONDITION <br /> RONDITION [] DESTRUCTION s <br /> . WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER E <br /> PUMP INSTALLATION E7 PUMP REPAIR 0 PUMP REPLACEMENT ❑ X-1 <br /> DISTANCE TO NEAREST.: SEPTIC TANK 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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary . Type of Grout <br /> 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: 2State Work Done Remy , e � <br /> DESTRUCTION OF WELL.: Well Diameter 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 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 F A GROUT INAPECTLON PRIOR TO GROUTING AND A FINAL-, INSPECTION. <br /> SIGNEDTITLE: DATE: <br /> cr DR W PL L N ON REVERSE S D <br /> FOR D PAR MENT US ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a2 -70C <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIQ <br /> INSPECTION BY DATE IV INSPECTION BY <br /> EH 142.6_ Rev. 12-77 __ __-.._._.- _ 1 /W 2M <br />