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. 4 J <br /> SAN JOAQUIN ,LOCAL HEALTH DISTR1C1 ` <br /> FOR FFICE USE: .. 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <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 /> C~ J 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 /> Loaau» County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. /- <br /> EXACT STREET ADDRESS z CITY/TOWN - <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name, License# l PhoneS22--Ad3 <br /> T$ CERTIFICATE OF WORKMIAN S COMPE"1S TIO"1 I"ISURA"10E ON FILE WITH SJLHD? YES <f��NO <br /> TYPE OF WORK (Check) : NEW WELL_ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CH ORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR ❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .. <br /> y PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATfI.OW ¢ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �omestic/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 <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: 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 far s permit'is issued, I shall <br /> not employ any person in such manner as to bec e subject Wrsp;9O s Compensationlaws of Calif rnia."I WILL CALL F R GROUT INSPEC PRIOR TO GROUTI AND AF AL` I . <br /> SIGNED TITLE: DATE <br /> R W PLOT PLTN ON RSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE �—3 fZ <br /> ADDITIONAL COMMENTS: ox <br /> PHASE II ---GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE.Z �� _ INSPECTION BY DATE <br />-EH 1426 Rev. 12-77 __ 1/78 2M <br />