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a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT e <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued6-�- <br /> (complete In Tri pl1cae). <br /> Application is hereby made to the San Joaquin Local Health District" for a permit to construct <br /> and/or :install the work�iherein `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 `..cs c� CITY/TOWN� <br /> ` Phone <br /> f Owner's Name <br /> City o <br /> Address- <br /> Contractor's Name -019 <br /> � , I License // I Phone -Z <br /> .IS CERTIFICATE OF WORKMAN'S COMPENSATION IC�SURA}� ON FILE WITH SJLHD? YES 0 <br /> } TYPE OF WORK. (Check) : NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION(:J _ <br /> WELL CHLORINATION [3 „WELL .ABANDONMENT 0 OTHER 0 <br /> _ q PUMP INSTALLATION 0 :PUMP REPAIR p.. ` PUMP REPLACEMENT-Cl t <br /> DISTANCE TO NEAREST: SEPTIC TRNICSEWER LINES r � ,PIT PRIVY <br /> SEWAGE DIS P L FIELD CESSPOOL/SEEP'AUE PIT OTHER <br /> PROPERTY LINED-'4''PRIVATE DOMESTIC WELDPUBLIC DOMESTIC WELL -� <br /> INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> -Industriali Cable Tool Dia. of ,Well Excavation <br /> r Domestic/private) Drilled Dia. of Well Gasing`c <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ', Gravel Pack Depth of Grout'sea <br /> CEA-4 f-1111: <br /> Cathodic Protection Rotary _ .. -,..:;Type-of Grout <br /> Disposal Other Other Informati.on ., <br /> k__777 Geophysical ;� - - Surface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor <br /> ;Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ! (7 State Work Done <br /> DESTRUCTION OF WELL: 'Well Diameter Approximate Depth - <br /> bescribe Material ana Procedure <br /> 11 hereby certify that IJ have prepared this appl,icati_on •and-that the work will be done in accordant <br /> With San Joaquin County; Ordinances; State Laws.,1and -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 OVT IWATION PRIOR TO GROUTING AND A° FINAL INSPECTION. <br /> ISIGNED TITLE: DATE: H „ Z <br /> �DRAW PLUT PLAN ON REVERSq SID <br /> FO EPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 111 FINAL INSPECTION <br /> INSPECTION BY DATE�d-� ;. INSPECTION SY W ; DATE / 1- <br /> EH 14 26 Rev. 9/78 2J1J -..M 78 ....Y M _ <br />