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k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F.QR-'.0RFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 . Permit No. 7q-505 ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 J G ¢ `' CITY/TOWhI~ <br /> Owner's Name - Phone .p <br /> Address [�, City <br /> Contractor's Name— LA— 0 k Li cense#/G 23 7I Phone -41 <br /> IS CERTIFICATE 'OF WORkMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES _ O <br />' TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [3 DESTRUCTIONI�. . .� <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER C3 <br /> k PUMP INSTALLATION 51 PUMP REPAIR O PUMP REPLACEMENT Q '" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL F ELD CESSPEL/SEEP'AGE- PIT OTHER <br /> 'P,ROPERTY LINE - .PRIVATE DOMESTIC WELL.-------. PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL .. CONSTRUCTION SPECIFICATIONS <br /> Industria `•Cable Tool w: Dia. of W611 Excavation <br />. —Drilled, a <br /> Domestic/private � _Di.a.._.ofwWe1.1_Ca.sa.ng <br /> w-- °-�Ooinesti�JpubT7c - DHNven Gauge of Casing <br /> - Irrigation _7­—Gravel Pack Depth of Grnu`t- Sea <br /> Cathodic Protection t Rotary Type of Grout' r <br /> Disposal - Other, - . ~TOther Information <br /> '--7—Geophysical .9 r Surface Seal Installed by: <br /> PUMP- INSTALLATION: Contractor <br /> Type f Pump H.P. 0 - w <br /> PUMP REPLACEMENT: St to Work Done -- <br /> PUMP REPAIR: ❑St to Work Done <br /> DESTRCTiON OF WELL: Well DiAeter F 3Approximate Depth - <br /> Describe Material and Procedure <br /> I hereby certify that I haveiprepared 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;ar 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 /> 5 laws of California. <br /> I WILL CAWFOR.A GROUT IXSPECTION PRIG TO GROUTING AND `FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: �, — /7 <br /> ON REVERSE DE <br /> FOR ,DEPA,RTMENT USE ONLY <br /> PHASE I <br /> A .P�LICATION ACCEPTED BY DATE C /! <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FLNAL INSPECTION <br /> INSPECTION BY C,__ DATE INSPECTION BY DATE -a $ <br /> tEH 14 26 Rev. 9/78 9178 ' 2M <br />