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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 - �-7� <br /> j <br /> This Permit Expires 1 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 i <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name_ ► Cal=�f� 1." C�, ' ,��,. Phone 4?9',?- 174//Address . 1?2 y_ W. .., /� .U✓S _. City �` °? <br /> Contractor's Name Czd91?1e '' _1� 09_Q 4,i cense# W Z Phone_Y <br /> & <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURA"NCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN D RECONDITION ❑ DESTRUCTION❑ �1 <br /> WELL CHLORINATION Q WELL,ABANDONMENT a OTHER 0 W ' <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER NES 60 4 PIT PRIVY_ <br /> SEWAGE DISPOSAL' FIELD "CESSPOOL/SE PAGE PIT '`OTHER "" - <br /> ► PROPERTY LINE -. PRIVATE DOMESTIC WELL f- -- PUBLI DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel Excavation Q <br /> Domestic/private ,. , Drilled Dia, of Well Casing_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic ProtectionRotary Type of Grout - T <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. R <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: Q State Work*Done' <br /> DESTRUCTION OF WELL: /Well Diameter Approximate Depth <br /> Describe Materia 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 s'ignature certifie-s the--following: <br /> "I certify that in the performarice-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." F <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: Ll W All DATE .2,2 r.__ <br /> (DRAW PLOT PLAN ON REVERSE SIDE_ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J 1 ?8 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 - 1/78 2 <br />