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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.�/mss <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 County Ordinance No. 1862 and the- Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS_ f 39/� ,� �$�' �` J CITY/TOWN <br /> Owner's NamePhone ��� •� _ — <br /> Address L.EM City, z 7 <br /> Contractor' s Name /$ R/ UZ4Ei-C.. ] �gL4 �C�- --- ----- License# 7f� ?�'hone� - 3�,;z _ <br /> -- <br /> I5 CERTIFICATE OFsWORKMAN'S COMPENSATION TNSURA"!CE ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK (Check) : NEW WELDEEPEN ❑ RECONDITION ® DESTRUCTION[n - <br /> WELL CHL INATION Q - WELL ABANDONMENT 0 OTHER 0 - W <br /> PUMP INSTALLATION M PUMP REPAIR O PUMP REPLACEMENT M <br /> DISTANCE TO NEAREST: SEPTIC TANK__CAo SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> - PROPERTY LINERIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y� <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 by: <br /> r` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an —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 signature certifies the following: <br /> "I certify that in the performance of, the' wo-rk 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 CAL4 FOR A UOUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ' TITLE: DATE: <br /> DRAW PLT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I z�r 3- 95 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />