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F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICEFOR USE: 1601 E. Hazpltan Ave. , <br /> Stockton, CA 95205 Permit Na. 7.q .?^� -- <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued -7 <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete In Triplicate <br /> lApplication 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 0 <br /> District. <br /> EXACT STREET ADDRESS 44 CITY/TOWN <br /> Owner's Name S' Phone r <br /> Address 9r0,9 Ci ty .. ` <br /> Contractor' s Name <br /> i cense 2 Phone r! <br /> IS CERTIFICATE OF WORKMAN'S COMPCNSATIO1I TtIS IRA 1QYON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEPrb RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION C1 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 <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> y 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 /> t i 4 <br /> k'PUMP, INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:- „ Q State Work Done <br /> PUMP REPAIR: tate Work- Done iQce <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> EI hereby certify that I have prepared this application and that the work will be done in accordani <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca' <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 /> iI WILL CAL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ,' SIGNED TITLE: DATE: <br /> DR W PLOT FLTN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /.2 -7�F <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION ti PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C _ A -E <br /> 1_ 7 8 2M <br /> .ru 1n9r Deu 19-77 <br />