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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. "I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued&5_ <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 /> EI <br /> EXACT STREET ADDRES r[/ CITY/TOWN f' <br /> Owner's Name Phone } <br />'f Address City <br /> Contractor's Nam , ' <br /> VLikens Phone7S �3�GeG_ <br /> { <br /> 1S CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES No. . � 3 <br /> f TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION Q DESTRUCTIONC] <br />` WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER(J <br /> PUMP INSTALLATION PUMP REPAIR C1 RUMP REPLACEMENT <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIS— OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL <br /> 3 INTENDED USE TYPE OF WELL., CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool. Dia. of Well Excavation <br /> estic/private, Drilled Dia. of Well; Casing <br /> Domestic/public Driven f+ Gauge of Casing µ{ ' ` - <br /> Irrigation Gravel Pack Depth of gout <br /> Cathodic Protection Rotary ..-,'Type of Grout <br /> Disposal her -Other InformationN <br /> Geophysical .. <br /> Surface al Installed by: <br /> PUMP INSTALLATION: Contract <br /> Type of Pup H:P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done . <br />* DESTRUCTION OF WELL: Well Diameter <br /> Approximate" <br /> Depth Depth 1: <br /> Describe Materia an Procedure <br /> I hereby certify that I 'have prepared this application and that the work will be done. in accordance <br /> frith San Joaquin County ty Ordinances, State Laws , and Rules and Regulations of the San Joaquin �Local <br /> Health District. Home owner or licensed agent's signature certifies the followin.g:k <br /> Jm <br /> I <br /> "I certify that in the performance of the work for which this permit is issued, I ,shall I <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws oflifornia." 1 <br /> :I WILL CAL OR �INSPE�Cj4ft.4.RiA GR UVTO GROUTING AND INAL INSPECTION. <br /> TITLE• DATE: <br /> D 0 ,} <br /> L N ON RE SE IDE <br /> �7�FO EP RTMENT USE ONLY <br />!PHASE I <br /> jA PLICATION ACCEPTED BY <br /> DATE.__ <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE Ii ROUT INSPECTION PHASE III FINAL INSPECTION <br /> EIN,SPECTION BY DATE <br /> �� ,, INSPECTION BY DATE • E. <br /> jEH 14 26 Rev. 9/7 9 . 78_ 2M .i <br /> t- <br />