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Co kz'L eA SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFF110E USE: —�, 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. Zr Z <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 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 Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS It �s A411 CITY/TOWN <br /> Owner' s NamePhone <br /> Address - City <br /> Contractor' s Name ¢// ` Li cense#, M 21,,-�hone <br /> IS CERTIFICATE OF WORKMAN'S MraF6ATT01111 INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION C3 DESTRUCTION[� <br /> WELL CHLORINATION p WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR® PUMP REPLACEMENT ED <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. <br /> PUMP REPLACEMENT: p State Work Done <br /> PUMP REPAIR: Ostate Work Done C.44e2w,6 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 INSPECT M PRIOR-10 GROUTING AND A FINAL INSPECTION. <br /> SIGNED LE: DATE: i <br /> Q AW P OT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEel"I-Ap- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI pHA 7,YVF-VVAL I ECTION <br /> INSPECTION BY DATE INSPECTION B DATE Z <br /> EH 1426 . Rev_ 12-77 .,1/78 2M - <br />