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SAN JUAQUIN LOCAL HEALTH DISTRICT /r7130-77 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7,7, 2 3 I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3 -.-2.7 ,72 <br /> This Permit Ex ires 1 Year From Date Issued -7-1--7,1 <br /> Nr <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 /> �'oaqui n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS �. CITY/TOWN <br /> Owner's Name Phone <br /> Address , V City <br /> Contractor's Name ✓. License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"J +INSURA"ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL M-- DEEPEN d RECONDITION C3DESTRUCTION 5g --- N <br /> 1F. , WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER ❑ W <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER u' <br /> PROPERTY LINE. -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL n <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of"Well Excavation <br /> --A,,::::��Pomestic/private ,—Drilled Dia. of Well Casing , <br /> t Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seald <br /> Cathodic Protection Rotary Type of Grout �— <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: O State Work Done <br /> DESTRUCTION OF WELL: Well Diameter % Approximate Dept dL <br /> Describe Material and Procedure ^ / ti►fc <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 C L FOR A WOUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �NON DA�: '37—/5-7W. . <br /> DR�WPL�OTPLSIDE <br /> FOR DEP RTMENT USE ONLY ..1 <br /> PHASE I � �w , <br /> APPLICATION ACCEPTED BYX9 `� ATE <br /> ADDITIONAL COMMENTS : tv VV A , ,a <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 y_ 1/ 2M <br />