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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Permit No. <br /> Telephone: 2,(209) 466-6781 <br /> 4 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> _ 7 <br /> (CompleteInTriplicate) <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 1 -7 -. Iq reV CITY/TOWN_ <br /> L� <br /> Owner's Name Phone , 6 / <br /> Address u <br /> City <br /> Contractor's Name , Lic nse ., <br /> .. _ <br /> i5 CERTIFICATE OF WORKMAN'S COVIRENSATION INSURAfMC-- y.0..._FILE_,WITFI_.SJ.LHD?--Y.ES— <br /> TYPE OF WORK (Check) : NEW .WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WEL! CHLORINATION D WELL ABANDONMENT 0 OTHER❑ <br /> ( PUMP."INSTALLATION ❑ PUMP REPAIR©-. - PUMP REPLACEMENT EQ-- c <br /> DISTANCE TO NEAREST: ' SEPTIC TANK_ SEWER LINES PIT PRIVY <br /> -,SEWAGE DISPOSAL FIELD /e/0 CESSP OL/SEEPAGE PI OTHER <br /> C =PROPERTYLIN ' PRIVATE DOMESTIC WELL PUBLIC D MESTIC WE�L <br /> l ; INTENDED -USE -f-, : TYPE OF.-WELL.. A CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia, of We 1 Excavation <br /> Domestic/pri`vate Drilled Dia, of Well Casing <br /> Domestic/pgblicp Driven Gauge of Casing <br /> Irrigation , Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout - - -' <br /> Disposal Other Other Information <br /> rGeophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> , Type of Pump - H_.P µ <br /> PUMP REPLACEMENT: <br /> Q'State W �T <br /> ork Done <br /> PUMP 'REPAIR: ❑State Work Donee k <br /> DESTRUCTION OF WELL: Well Diameter_ , <br /> - Approximate Depth <br /> " tescribe'Mate r a and Procedure <br /> I hereby certify that I have'"prepar d this -application and that the work will be done in accordan4 <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> ► Health District.. Hume 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 n_s.uch_manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> ' I WILL CALL FOR A GR UT INSPC7IO <br /> SIGNEN.PRIOR TO GROUTING AND A FINAL INSPECTION.D f <br /> '�-- TITLE: DATE: _ <br /> D PL ON REVERSE SIDE <br /> PHASE I R DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r / 7 <br /> ,ADDITIONAL COMMENTS: ""� DATE <br /> ' PHASE TI GROUT INSPECTION <br /> INSPECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE 30 J <br /> LEH 14 26 Rev. 9/78 9178 <br />