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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> EOR FFICE USE: 1601 E. Hazelton Ave. ; Stockton, CA 95205 Permit No. 71-4Z , <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -/ <br /> (complete In Triplicate) <br /> Application is .hereby made' to the San Joaquin Local• Health District for a permit -to cons'trud't <br /> and/ install the work herein described. This- application. is made ,in compliance with San.' <br /> Joaquin County Ordinance No: 1.862 and the Rules and' RegU1ations of .the San Joaquin Local Health <br /> District. ' ' <br /> EXACT STREET ADDRESS /21 CITY/TOWN'e'-4 . <br /> Owner's Name ",,,, ;� ' Phone <br /> Address v _ / f2 City � . <br /> Contractor's .Name Li cense# JG S/ .3Q Phone <br /> IS CERTIFICATE OF WORKPAN"S COMPENSATIOM INSURANCE ON FILE WITH' SJLHD? YES,_L NO <br /> TYPE OF WORK (Check) : NEW'WELL W, DEEPEN ❑ RECONDITION [] DESTRUCTION[2 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 � <br /> PUMP INSTALLATION PUMP REPAIRE1, PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK -cam SEWER LINES PIT PRIVY--0- <br /> SEWAGE DISPOSAL IELD CESSPOL/SEEPAGE PIT OTkER - <br /> PROPERTY LINEIQ-®-PRIVATE DOMESTIC WELL:: PUBLIC DOMESTIC WELL - n!�, <br /> INTENDED USE TYPE OF-WELL_ CONSTRUCTION SPECIFICATIONS <br /> Industrial F,. e. ' Cable Tool Dia, of Well Excavation I L k <br /> _,--Domestic/private. ` ` _ _�_Drilled Dia. of Well Casing e- <br /> Domestic/public V Driven Gauge of Casing Jz <br /> 'J�- I rri gation 7 Gravel_ Pack __:.. ...Depth .of Grout — - - f <br /> Cathodic 'Protection Rotary Type. of-Grout _�"€���,r,7--.p <br /> Disposal E Other Other Information <br /> Geophysical Surface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF 'WELL: Wells Diameter Approximate Depth <br /> PP p <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and .that the work will be done in accorda <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San .Joaquin Loc <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. " +1 <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> r <br /> SIGNED TITLE: . DATE: Z2 -7f <br /> ` DR W PL T PLAN ON REVERSE SIDE ` <br /> FOR DEPARTMENT USE ONLY <br /> I RHAS£ I <br /> APPLICATION ACCEPTED BY DATE 0 <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION PHASE III 'FINAL INSPECTION <br /> iINSPECTION BY DATE . INSPECTION BY DATE <br /> 1EH 14 26 Rev. 9/78 9/78.- . 2M <br />