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SAN JOAQUIN LUCAL HLAL IH U1J 1 K1U 1 <br /> ;'FICA USE: 1601 E. Hazelton Ave.., -Stockton, CA 95205 Permi t No. 7 9- 2- <br /> Telephone:. (209) 466-6781 $f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -.;2-7 <br /> This Permit Expires 1 Year' From bate hssued , <br /> / Complete In Triplicate <br /> AQplication is hereby made to the San Joaquinlocal Health District for a permit to construct <br /> and/or install the work herein described., This application is made in compliance with San r <br /> Joaquin County Ordinance No. 1862 -and the Rules and Regulations of the San Joaquin Local Health <br />�istrict. d <br /> EXACT'. STREET ADDRESS e�3l I � CITY/TOWN <br /> Owner' s Name' Phone 3J s�o . <br /> Address '?> _ City <br /> Contractor's Name" License# Phone <br /> IS CER7TFICATE OF WORKMAN'S COMPE.NSATIO'! I'dSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLIL] DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ . PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: ' -,�SEPTIC TANK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL/FIELD + CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY,.LI,N-E`- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Di&. ,of-Well Casing ' <br /> Domestic/public Driven _.Gauge of Casing <br /> Irrigation Gravel. Pack-..- ,, Depth- of Grout Seal ' <br /> Cathodic Protection Rotary .. -.t-�` "Type of- Grout � � <br /> Disposal `Other "" Other Informatta-ft " <br /> Geophysical �,. Surface Sea:1Installed b <br /> 4 <br /> PUMP4IN5TALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Don <br /> PUMP REPAIR: ❑State Work Done <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' k 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 CAL GROUT JNSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ' <br /> SIGNED TITLE: DATE:, 3 ' <br /> (DRAW PLOT PLVN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY -T <br /> ' <br /> APPLICATION ACCEPTED BY DATE�g 7r�. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION . PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> 78 2M , <br /> EH 1426 Rei 12-77 <br />