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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave:, Stockton, CA 95205 Permit No. 7r 1067 <br /> --_-_� Telephone:. (2D,�.) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ?-/�- <br /> 4 <br /> This Permit Expires 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 const ct <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. �7`� '-,3 S, l7 3 C o-O Z- <br /> EXACT STREET ADDRESS MOAA CITY/TOWN <br /> Owner's Name Phone <br /> Address & City <br /> Contractor's Name License# Phone__?tk_.2&/4 <br /> IS CERTIFICATE OF WORKMAN`S COMPENSATION IINSURAt10E ON FILE WITH SJLHD? YES V NO <br /> TYPE OF WORK (Check) : NEW WELL[" DEEPEN fJ RECONDITION Q DESTRUCTION Q <br /> WELL CHLORINATION p WELL ABANDONMENT p OTHER 0 J <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT Q 41, <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVY fin, <br /> SEWAGE DISPOSAL"IELD CESSPOOL/SEEPAGE PIT OTHER— <br /> PROPERTY <br /> THER PROPERTY LIK011'PRIVATE DOMESTIC WELLJ- 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 Casin42 44 <br /> g <br /> —Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b -- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump __ H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana Procedure f <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 signat a certifies the following: <br /> "I certify that in the performance of the work for <br /> ich this permit is issued, I shall <br /> not employ any person in such manner as to become ubject to Workman 's Compensation <br /> laws of California." <br /> I WILL CALL FOR A G UT IN EC ON OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: ' r' <br /> W PLOT PL N ON REVERIE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I, DATE 7 ZZL <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II , AL SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E. 14426 Rev. 12-7.7___ ���- 1 /78 9M <br />