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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7 `- <br /> Telepho'ne: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Ex ices 1 Year From Date Issued <br /> Complete 1n 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 ADDRESSh A CITY/TOWN ,Gc c i <br /> Owner' s Name Phoney_ r <br /> Address r S`' -e- '2.— City T©rte <br /> Contractor's Name A AIZ,Za Ad gS ;✓ , License#'. 50/D„ Phone <br /> IS CE=RTIFICATE OF WORKMAN'S C011•1PENSATIO'N INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL J�E" DEEPEN 0 RECONDITION ❑ DESTRUCTION C2 <br /> WELL CHLORINATION C1 WELL ABANDONMENT 0 OTHER f_] J <br /> PUMP INSTALLATION D PUMP REPAIR❑ PUMP REPLACEMENT ❑ � ' <br /> DISTANCE TO NEAREST: SEPTIC TANK'eV` SEWER LINES /a `- PIT PRIVY la`f <br /> SEWAGE DISPOSAL FIELD/ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE54 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven w Gauge of Casing ZZ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary" Type of Grout %P <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor H <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WE'LL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify- that I have-prepared this-application and that the work will be done in accordanc <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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEQTITLE: DATE: -7 z 71 <br /> DR W PLOT PL N ON REV E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYW&4A(dDATE " 7e� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE-P' -;-4,7;? <br /> FH 1426 RP_v_ 12--77 1/78 2M <br />