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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.78.//,99 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I 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 (D `A CITY/TOWNS a c <br /> Owner's Name C Phone <br /> Address CitylvrpgA <br /> Contractor' s Name ©. License# D Phone -- _3 <br /> IS CERTIFICATE OF WORK'IAN'S CO"iPENSATIO'N I'1SURAINCE OM FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL V) DEEPEN CI RECONDITION ❑ DESTRUCTION d o <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT El <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 ;SPECkIFICATIINS <br /> n ustrial Cable Tool <br /> Dia. of Well Excavatioi� Domestic/privateDrilled Dia. of Well Casing Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout f—, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: - <br /> PUMP INSTALLATION: Contractor '�;TA A " <br /> - \\ ZA'r I Vn k Q <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: F] State Work Done <br /> PUMP REPAIR: CIState 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 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 GRWT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> WPL T PLAN ON REVERSE E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DAT �( - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D TE <br />.FH 142 P_P_y_12_77 LST�► - - 1178 2M <br />