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it4, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORDF..F� E 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 S^ <br /> This Permit Expires I Year From Date Issued <br /> f Complete In Triplicate <br /> ` AQplication is hereby bade 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 /> `oaquin County Ordinance No. 1862 and the Rules and Regulations of the San ,Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �` ,S CITY/TOWN 01�9 <br /> Owner' s Name Phone 31 <br /> 6 <br /> Address CityZ. <br /> Contractor' s Name License# ' o `Phone�a-3 5 <br /> 7S CERTIFICATE OF WORKMAN'S C011IPENSATIOM INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 54 DEEPEN ❑ RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION 0 . . WELL ABANDONMENT 0 OTHER 0 <br /> PUMP _INSTALLATION- %,,. _PUMP_-RE'PA'IR❑ PUMP REPLACEMENT-.[], —. <br /> —. , <br /> DISTANCE TO NEAREST:` MSEPTIC TANKnon 6 SEWER LINES PIT PRIVY. <br /> SEWAGE DISP 5RL 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 ra <br /> Domestic/private Drilled , Dia. of Well Casing D <br /> Domestic/public Driven Gauge of Casing_ <br /> Irrigation Gravel ,P.ack Depth of Grout' Seal` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical E Surface Seal Installed b -:7[ IALkT�4- <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT: F2_5tate Work Done — <br /> PUMP <br /> one —PUMP REPAIR: ❑State Work Done, <br /> DESTRUCTION OF WELL: Well Diameter _ t � ' � Approximate Depth rad <br /> Describe Material and Procedure <br /> C I hereby certify that I have prepared this application and that�the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San;Joaquin Loca <br /> Health District. Home owner or licensed 'agent' s signature.1 certifies the following: <br /> "I certify that in the performance of'the work for wh%ch this permit is issued, 1-.shall <br /> not employ any person in such manner' as' to become subject to Workman' s Compensation <br /> ` laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR -TO-GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: - � iQ 7 <br /> R W PLOT PLAN ON REVERSE- SIDE) tj FY <br /> FOR�DEPARTMENT USE ONLY <br /> PHASE I z.. --..- -� <br /> APPLICATION ACCEPTED BY - - _ -- - -�- ' = DATE—_ <br /> Z 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> i INSPECTION BY DATE INSPECTION BY ( - e&Y2 „ DATE 7 2•- ) <br /> , EH 1426 Rev- 12-77 1/78 M <br />