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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ., <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3:5--,;� <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 /> EXACT STREET{ADDRESS ZOO&-y' Al A;J 4 /V CITY/TOWN , <br /> Owner's Name J6p� phone <br /> Address ✓ ocl L City <br /> .:Contractor's Name a*_. License1V 7YS��hone Wy6 f <br /> IS CERTIFICATE OF WORKMAN'S CO". NSATION INSURANCE ON FILE WITH SJLHD? YES NO, <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN O RECONDITION ❑ DESTRUCTION( <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 W <br /> PUMP INSTALLATION [] PUMP REPAIR 0 PUMP REPLACEMENT ❑ �`' <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESES PMOL/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 /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ..fes .6 H. 2 <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: (State Work Done a4 y _ j,, , 4- 1/ <br /> DESTRUCTION OF WELL. Well Diameter Approximate Depth <br /> Describe Material ana Procedure <br /> 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 INSPKTIQNPRT1aR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTLE: DATE: <br /> D PL T N REVERSE SIDEJ <br /> OR DEPARTMENT USE/ONLY <br /> PHASE I -- <br /> APPLICATION ACCEPTED BYX:]�� Av" DATE a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 ��� 9/78 2M <br />