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�! SAN JOAQUIN LOCAL •HEALTH DISTRICT ,r <br /> FFICE USE: ;1 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. " <br /> Telephone: (209) 466=6781 <br /> �1APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -- Date Issued(�,-�O-/ <br /> This Permit Ex ires 1 Year From Date Issued <br /> I"F Complete In Triplicate <br /> 'Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> sand/or install the workIherein described. This :application is made in compliance with San <br /> ucaquin County Ordinance No. 1862 and the Rules and Regulations of the San' Joaquin Local Health <br /> Flistr�ct. <br /> EXACT STREET ADDRESS_____ '[� - ��t.Ge� - CITY/TOWN <br /> Owner' s Name f Phone _ <br /> Address City <br /> Contractor's Name License#� 1_ Phone S <br /> U <br /> IS CERTIFICATE Of WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br />, TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION. `u <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT p <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 /> i Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ; Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical I Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /># Type of PumpT H.P. <br />! PUMP REPLACEMENT: 'b State Work Done <br /> PUMP REPAIR• ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> u <br /> r <br /> I hereby certify that Il'have prepared this application and that the work will be done in accordant( <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 following: <br /> i "I certify that in the performance of the work for which this permit is issued, I shall <br />� . not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br />,- I WILL CA OR A GROU !INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED `� TITLE: <br /> d DR W PLOT PL N ON REVERSE SIDE <br /> I FOR DEPARTMENT U$�€ ONLY <br /> PHASE I j <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: iI <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY DATE <br /> l /78 2M <br /> FEH_ 1426 -Rev. 12-77 "� <br />