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SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No, •7_1A" <br /> Telephone.: (209).466-6781 <br /> 'J 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 hereinldescribed This application is made in compliance with San F <br /> Joaquin County Ordinance No. 1862 and ,the Rules and Regulations of the San :Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �' C� CITY/TOWN Ga <br /> Owner's Name I/` Phone <br /> Address. d 166City <br /> Contractor' s Name License 7I- Phone <br /> IS CERTIFICATE OF WORKMAN", ("11M I0P! INSURANCE ON FILE WITH SJLHD? YES 4L< Ii0 <br /> TYPE OF WORK (Check) : NEW WELL C! DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION ❑11 PUMP REPAIRf !_ PUMP REPLACEMENT [3 <br /> DISTANCE TO NEAREST: SEPTIC DANK SEWER LINES PIT PRIVYOTHEROTHER <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE <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 Iof Casing <br /> I:rrigat,ion Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump <br /> H•P• i <br /> PUMP REPLACEMENT: [] State Work DoneOle <br /> j <br /> PUMP REPAIR: (E State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia 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 INSPE IO ORT GRO TING AND A FINAL INSPECTION. <br /> SIGNS LE: DATE: t <br /> ZAW—PLOT PLA REVERSE ID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION B DATE , a� <br /> 1`/78 :" 2M <br />