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ton, /o SAN JOAQUIN LOCAL, HEALTH DISTRICT _ <br /> F FFI E USE: <br /> ­ -' 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 —Ief-6o <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/a 6 78 <br /> This Permit Ex fres 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS nr, .� /�(/ Lit i e A4,10, 'E" <br /> CITY/TOWN <br /> Owner's Name <br /> Phone <br /> Address - <br /> Contractor's <br /> ddressContractor's Name License# hone <br /> IS CERTIFICATE OF WORKMAN'S C ENSATION INSURANCE ON FILE WITS! SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR M PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/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 We 1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ <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 Insta led b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ®State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce 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 INSPECT PRIO 0 GROUTING AND A FINAL INSPECTION. <br /> iIGNED LE; DATE: <br /> D W P T PL N ON REVERSE SIDE <br /> 'HASE I O R DEIAKTMtNI USE ONLY <br /> aPP''CATION ACCEPTED BY �/ DATE`f4 <br /> ,D _ ZONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHA I F AL I ECTION <br /> NSPECTION BY DATE INSPECTION B DATE/ F2 <br /> H 1426 Rev. 12-77 1/78 2M <br />