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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFOFFICE USE: 16C E. Hazelton Ave. , Stockton, CA '5205 Permit No. 7 / <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedL <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 A CITY/TOWN <br /> Owner's Name ?— =� � Phone 3; ' <br /> Address — City �7// <br /> Contractor' s Nam V License# �Nhone a c <br /> IS CERTIFICATE OF WOR 'IAN'S CO"PE"dSATIOPI INSURA"10E ON FILE WITH SJLHD? YES <br /> NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN p RECONDITION [] DESTRUCTION[] <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER r--] � <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK�1_t�_C_y -rSEWER LINES D� 't PIT PRIVY <br /> SEWAGE DISP SO __AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 7�CableTool Dia. of Well Excavation 16 <br /> Domestic/private Drilled Dia. of Well Casing s// <br /> Domestic/public Driven Gauge of Casing /I <br /> — <br /> Gravel Gravel Pack Depth of Grout Seal A/; <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 U �, H.P. <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: ❑State Work Done <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 accordant <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 P y an y person in such manner as to become subject to Workman 's Compensation <br /> laws of California ." <br /> I WILL C FORA G INSPE TION PRIOR TO GROUTING AND A FI t IN PECTION. <br /> SIGNED - TITLE:���� —<' <br /> DR W PLOT PL N ON REVERSE STI DATE: <br /> PHASE I FOR DEPARTME USE ON fi <br /> 4r^^PLICATION ACCEPTED BYE DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY <br /> :H 14 26 Rev. 9/78 �� - �-�-- DATE <br /> q/7R 2M <br />