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SAN JOAQUINILOCAL HEALTH DISTRICT <br /> -r <br /> `USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permi t No. -.y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ires 1 Year From Date Issued <br /> . Complete In Triplicate <br />' Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Fand/or install the work herein descr-ibed. This application is made in compliance with San <br />' �oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT -.STREET ADDRESS ' <br /> �Z' � �� n CITY/TOWN-��� r.� <br />'Owner's Name a to <br /> Phone <br /> Address <br /> Contractor' s Name `` City <br /> tyd <br /> �JtLicense#_/���_ PhoneIS CERTIFICATE OF WOP,KtiAlINSURA^lCEIOfI FILE WITH SJLHD? YES NO <br /> TYPE 0_F WORK (Check) : NEW WELL[ DEEPEN 0 RECONDITION ❑ DESTRUCTION EI <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHER 0 �-- <br /> PUMP INSTALLATION E] PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK "SEWER LINES PIT PRIVY C' ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL : <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sear <br /> Cathodic Protection : Rotary Type of Grout r <br />-Disposal 'Other } - Other Information <br /> Geophysical <br /> .. Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of- Pump H.P. <br /> PUMP REPLACEMENT: [9 State Work Done <br /> des _:• - w / f <br /> PUMP : (]State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce u.re <br /> I hereby certify that I have prepared 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 or licensed agent's signature certifies the' fa1lowing: ' <br /> 11I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ o <br /> P y an y person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECT N PRIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED r <br /> ITLE: DATE: <br /> D AWP T PL 'ON REVERSE SIDE <br /> (f <br />'RASE I FOR DEPARTMENT USE ONLY <br /> IPPLICATION ACCEPTED BY DATE � -7SIDDITIONAL COMMENTS:. <br /> PHASE II GROUT INSPECTION HAS II FINA INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE 7 F-11 " <br /> X26 Rev. 12-77_ ,,,, <br />