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S JOAQUINLOCAL HEALTH DISTRICT permit No.1L - <br /> iR FFICE USE: 601 E�(iaz,Ito" <br /> Ave:, Stockton, CA 95,&-o <br /> l Telephoner (209) 0.66-6781 Date Issued 6-)6- <br /> APPLICATION FOR WELL GONSTRUCTION OR PUMP PERMIT <br /> This Permit-Ex fires l Year: From Date Issued „ <br /> Comp ete ' n Trip. icate _ <br /> plication is hereby made to the San Joaquin LocalHealth <br /> District made inrcompliancetwith nSan <br /> uct. <br /> J/or install the work herein described.,. This app <br /> aquin County Ordinance 1do. : 1862. and, the Rules and ,.Regulations of the San Joaquin Local Health <br /> strict. ..����� � <br /> -CITY/TOWN <br /> ACT .STRE.ET ADDRESS phone CG <br /> ner' s Name ko iA City <br /> dress <br /> License# Phone <br /> mtractor's Name - <br /> > CERTIFICATE OF WORKMAN'S COMPENSATIOI! INSURA"dCE ON FILE WITH SJLHD? YES NO ` <br /> IPE OF WORK (Check)':- -NEW WELL O DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION (l WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION..k( ; PUMP REPAIR n PUMP REPLACEMENT 0 <br /> ISTANCE TO NEAREST:', SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS7CL�IELD CESSPOL/SEEPAGE IT • OTHER <br /> PROPERTY LINE -. PRIVATE DGRESTIC WELL PUBLIC DOFiESTIC WELL- C <br /> INTENDED USE ) TYPE OF WELL ab CONSTRUCTION SPECIFICATIONS <br /> Industrial Ca Tool Dia. of We Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> k'_ TY Gauge of Casing <br /> Domestic/public Driven <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> -Disposal i Other Other Information <br /> Geophysical f Surface Seal Insta ed y: <br /> )UMP INSTALLATION: Contractor <br /> Type of Pump S"u��/ S � <br /> PUMP-REPLACEMENT:4 ❑State Work Done <br /> PUMP .REPAIR: E7State Work Done <br /> DESTRUCTION OF WELL: . Wel:1c Diameter t Approximate Depth'_ <br /> Describe Mate a a roce ure <br /> I hereby certify that I have prepared this application and that the work will�be do in' accor <br /> with San Joaquin County Ordinances, State .Laws, and Rules and Regulations of the San Joaquin L <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 ih such manner as to become subject to Workman's Compensation <br /> laws'.bf California." <br /> I WILL CALL OR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> �� TnR ON REVERSE SIDE <br /> R DE R USE UNLY <br /> PHASE I DATE <br /> PPLIC TION ACCEPTEb BY <br /> ADDITIONAL COMMENTS: t PHASE I FINAL INSPECTION <br /> PHASE II GR UT IN ECTION �,�-�-�- <br /> , INSPECTIA, BY -- ° DATE INSPECTION BY� DATE <br /> 1/78 <br />