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Cc m le /0 14q SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE 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 ? <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 Countyrdinance No. 1862 and the Rules and Regulations. of the San Joaquin Local Health <br /> District. <br /> / 6 • <br /> EXACT STREET ADDRESS r � S ZJ -� � /f��a+ CITY/TOWN <br /> Owner's Name ct.v'L e, r 6. Phone <br /> Address0 Ci ty <br /> Contractor's Nam Licenser -7-,-.-sPhone el,6 74.7- -- <br /> IS CERTIFICATE OF WORKMAN Oi� ENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> — a <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN 0 RECONDITION [] DESTRUCTION F1 <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER M <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 b : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. y <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP ®State Work Done , .G/ <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 /> Taws of California." <br /> I WILL CALL FOR A GROUT INSPECT PVIOR--To GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE: /� DATE: 4 <br /> /IDRAW PUOT PL ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 7 PHASE IIA FINAL INSP CTION 7S <br /> INSPECTION BY DATE INSPECTION B AT£ <br /> FH 142f Pov 12-77 -- - 1/78 2M <br />