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R <br /> SAN JOAQIlIN LOCAL HEALTH DISTRICT . <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CAS 95205 Permit No. _SII <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued ���-� <br /> t (eomplete .In Triplicate) Il <br /> I 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' Regu1ations of the San Joaquin Local Health <br /> District. <br /> 'EXACT. STREET ADDRESS {� <br /> CITY/TOWN�^7`�� <br /> Owner's Name kla © Phone r <br />�. Address_- <br /> Contractor-'s-Nam <br /> - <br /> lf- ense# -- ---F - Phone <br /> IS CERTIFICATE 'OF WOftK3AN'S. COMPENSATION INSURANCE ON FILE WITH-SJLHD? <br /> .TYPE OF WORK (Check) : NEW WELL 0 DEEPEN D `RECONDITION [] DESTRUCTION%-'I � 11111" <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER C3 <br /> PUMP INSTALLATION PUMP REPAIR CI- - RUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEDER LINES PIT PRIVY <br /> - _ (� <br /> SEWAGE IAI <br /> PROPERTYLINE - PRIVATE D .MESTICPW�LLSEEPAGEPUBLIC DOMESTICRWE'LL <br /> i <br /> - INTENDED USE' � <br /> TYPE OF.WELL.-, CONSTRUCTION SPECIFICATIONS ,. <br /> Incrust Cable Tool Dia. of We Excavation77 0 <br /> -__Domest.ic/private Drilled Dia, of Well Casing <br /> ,_Domestic/public Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Sea <br />. �athodi c Protection Rotar _ - °-°-- <br />: `Disposal y Type of Grout <br /> Geophysical _ Other Information <br /> Surface Seal InstaTled-F. <br /> RUMP INSTALLATION:` Contractor IN e <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> ❑State Work Done <br /> PUMP REPAIR: <br /> QSt '¢ <br /> ate �Wor.k. Done k p <br /> DESTRUCTION OF ,WELL•, Well •Diameter <br /> -Approximate Depths _.,I <br /> Describe Mater-i an Proce C-Alo' re 1 <br /> I hereby certify thatI 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 signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shalt <br /> ; not' employ'any person in such manner as to become subject to Workman's Compensation <br /> laws of California.." f <br /> I WILL CALL. FOR'A GROUT INSP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN_ E m +~` <br /> L L ONTREV R� DATE: . . <br /> S SIDE <br /> PHASE I R DEPARTMENT USE ONLY r <br /> PPS LICATION ACCEPTED BY DATE `t Z1 7 <br /> RDOITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION M. <br /> INSPECTION BY PHASE II I L INSPECTION <br /> DATE 'INSPECTION BY DATE ` -/2 7 ; <br />�H, 14 26 Rev, 9%78 � � Y 9/78 <br />