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SAN JOAQUIN` LOCAL .HEALTH DISTRICT <br /> JOR OFFICE USE: 1601 E. Hazelton -Ave. , Stockton, CA 95205 Permit No. <br /> Telephone; '(209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 fora permit to construct <br /> and/or ,install the� work herein 'described. This application: is made in compliance with San <br />.oaouin County Ordinance No. 1862 and .the Rules and- Regulations of the San-Joaquin Local Health <br /> Distrsct, i <br /> EXACT STREETE �� CITY/TOWN .,' <br /> Owner's Name PQ Y-1 ,o. phone <br /> Address .. City <br /> Contractor's Name License# a Phone 2 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"!. INSURANCE ON FILE WITH SJLHD? YES �!� NO <br /> TYPE OF WORK (Check) : NEW WELL C} DEEPEN CO RECONDITION 0 DESTRUCTION C3 <br /> WELL CHLORINATION ELL ABANDONMENT OTHER <br /> PUMP INSTALLATION [►PUMP �REPAIRI3� PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <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 Seal 4 kj <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical urface Seal Installed by: <br />'UMP INSTALLATION: Contractor b—e-j� S <br /> Type of Pump �. H.P. <br />'UMP REPLACEMENT: r]State Work Done <br />'UMP REPAIR: (tate Work Done } ^ c <br />)CSTRUCTION OF WELL: Well Diameter n Approximate Depth <br /> Describe Materia an Procedure <br />[ hereby certif that I have prepared this application and that the work will be done in accordance <br /> Jith San J uinCo Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local '- <br /> iealth D'strict. Home wner or licensed agent's signature certifies the following: <br /> "I rtify that in t performance of the k for which this permit is issued, I shall <br /> no employ any pers n, in such mannr a to ecome subject t Workman's Compensation r <br /> 1 s of Ca ifo <br />' WIL CAL G UT I.NSECT0 T ROU G D A FVSPECTION. <br /> SIGNED ATE: ;DR PLOT PL N ON REVERS I <br /> -; <br />'f1AS E I FOR DEPART ENT USE ONLY <br /> iPPLICATION ACCEPTED BY DATEA5—A07 <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOW INAL IN ON <br /> NSPECTION BY DATE I 7CTION BY DATE <br /> H 1426 Rev. 12-77 I�t rA-0 <br />