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C© ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - 6 V <br /> Telephone: (209) 466.-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued l� 9 <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 Rles and Regulations of the San Joaquin Local Health <br /> District. fiIb I v , 5-00 ex vV ut se, <br /> EXACT STREET ADDRESS .*"t of pt)AW &JZ1 A#&,.� CITY/TOWN <br /> Owner's Name c ,� Phone <br /> Address 4,> A;L,,0p City <br /> Contractor's Name / License# L _72,j'�Phone i <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO. <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN CI RECONDITION,® DESTRUCTION 0 U' <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIRJM PUMP REPLACEMENT .[ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 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 Insta ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. /0' - <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: (NState Work Done A" <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 FOR A GROUT INSPECTION RI O GROUTING AND A FINAL INSPECTION. <br /> SIGNEDkfj ,e TLE: DATE: <br /> -4,A)k L L N REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `/S/7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE AII FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> EH 14 26 Rev. 9/78 9/78 ;LM <br />