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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFIC'E USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 Perm-i t Ao. <br /> Telephone: (209) 466-6781.. :. <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PE MIT Date Issued S <br /> (Complete In Trip] icate} � <br />' S6e �t�xJ,1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made to compliance with San <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San- Joaqui-n Local Health- <br /> District. <br /> EXACV STREET ADDRESS Q CITY/TOWN <br /> Owner's Name Phoneg. <br /> Address �. Cit. <br /> .. . <br /> Contractor"s Namy <br /> e License Phone: v �u <br /> IS CERTIFICATE -OF WORKMAN'S COMPENSATION INSU NCE ON FILE WITH SJLHD? YES 0' <br /> TYPE .OF WORK (Check) : NEW WELL II DEEPEN ❑ RECONDITION ❑ 4 DESTRUCTION 0 <br /> WELL CHLOR?NATION ❑ WELL-ABANDONMENT ❑ OTHER ❑ <br /> PUMP .INSTALLATION 0 . PUMP REPAIR❑ PUMP REPLACEMENT 0- <br /> DISTANCE TO NEAREST: SEPTIC TAN <br /> w SEWER LINES pPIT PRIVY <br /> -SEWAGE DISPOSAL2 CESSPOOL/SEEPAGE PIT--�.- OTHER, <br /> PROPERTY LINE/6PRIVAT ESTIC <br /> Y <br /> 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 .r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout «D <br /> ~ isposal Other Other Information � <br />--77-Geophysical S fa �Sea] Ins a ed <br /> PUMP .INSTALLATION; (Con <br /> 47 ' <br /> _ Type of Pump - H.P. <br /> PUMP REPLACEMENT: ❑State Work Done _r <br /> PUMP REPAIR: ❑State Work ,Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Proce ure i <br /> I hereby certify that I have prepared this appl'-icati-on-and that `the work will be done in 'accordance <br /> with San Joaquin. County Ordinances , State Laws , and Rules. and. Regul.ations of the San Joaquin Local •4 <br /> Health District.' Home owner or licensed-agent's signature certifies the following: _ <br /> "Ikcertify that in the performance of th . work for which this per`-mit is issued., I shall <br /> not employ any. person in such manner, as :to become su <br /> Taws of California. bject to Workman's Compensation A <br /> Z <br /> WILL CALL FOR GROUT I SPECTION� PRIOR TO GROUTING AND A'-FINAL- INSPECTION. x <br /> IGNED TITLE:_AggAill DATE: ; <br /> (DW PUT P L N ON REVS S SIDE <br /> R DEPARTM NT USE ONLY <br />?HASE ,I <br /> IPPLICATION�ACCEPTED 8Y <br /> 0DITIONA�LRCOWENTS:' - DATE 3 ,'' 7'9 <br /> PHASE II GROUT INSPECTIO PHASE III F NAL I PECTION. <br /> NSP ON BY DATE -7f INSPECTION BY <br /> TE Rev. 9/78 J .v <br /> 8 2M <br />