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rr �- <br /> ' d�*� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR' F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> _X APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -5 <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 construct <br /> and/or tinstall 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. <br /> EXACT STREET ADDRESS hl CITY/TOWN <br /> Owner's Name ,L.e- Phone <br /> Address J :L_ / /►f es c.. City . d ° <br /> Contractor' s Name License# Z2.J71,f-Phone ctL -7 i <br /> IS CERTIFICATE OF WO!?K"IAN'S COMPENS IO"! INSURAINCE ON FILE 'WITH SJLHD7 YES ISO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION DESTRUCTIONf:3 <br /> WELL CHLORINATION 0 WELL ABANDONMENT E'1 OTHER 0 <br /> PUMP INSTALLATION C] PUMP REPAIR® PUMP REPLACEMENT El <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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -;,o — <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: []State Work Done j d¢ blAe <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <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 signature certifies the following: <br /> "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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED !/ '� TLE: sttr_ DATE: <br /> W <br /> R OT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ <br /> 9DITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 'ECTION BY DATE INSPECTION BY ATE <br /> �9� <br /> ��fi Rev_ 12-77 _ � 1/78 2M <br />