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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR FFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No.Z f- 3 9 <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /- 7 <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 3 9�5��� CITY/TOWN <br /> Owner's Name c/Lo� Phone 3 61-- <br /> Address 16 '� fP / _ Ci ty 4'6-� <br /> Contractor's Name License# x-373 Phone �_�Q'= ��' � <br /> IS CERTIFICATE OF WORKMAN'S COMSPENSATION INSURANCE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION �'] DESTRUCTION[� w <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER ( .b <br /> PUMP INSTALLATION [I PUMP REPAIR C- PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY'' <br /> SEWAGE DISPOSAL T ELD CESSP OL/SEEPAGE PIT OTHER <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 T Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor kO <br /> Type of Pump <br /> H.P. <br /> d <br /> PUMP REPLACEMENT: rJ State Work Done _ <br /> PUMP REPAIR: 3State Work Done6-&:,,Q <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 /> laws of California. <br /> I WILL CALL M A bROUT INSPECTION P OR TO GROUTING ANDA FINAL INSPECTION.- Q" <br /> SIGNED TITLE: DATE:1 <br /> JA <br /> W PL ON REVERS S E <br /> PHASE I -7 <br /> FOR DEPARTMENT USE ONLY <br />�PPLCATION ACCEPTED BY r DATE y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C . DATE 7 za <br /> EH 14 26 Rev. 9/78 - _ 9/78 2M <br />