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Co �/ SAN JOAQUIN LOCAL' HEALTH DISTRICT 1 <br /> '.CE USE: l/ ' 1601 E. Hazelton Ave.-$ Stockton, CA 95205 Permit No.7��1,3a S'_ <br /> 7 . -AJ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued —7�L. <br /> This Permit :Ex ires 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 /> loaqui n County Ordinance No . 1862 and the Rules and Regulations- of the San Joaquin Local Health <br /> District.- <br /> J� <br /> EXACT STREET ADDRESS CITY/TOWN �v <br /> Owner's Name a rz Phone <br /> Address Le <br /> - City � , <br />` Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURANCE ON FILE WITH SJLHD? YES _ NO <br /> IkTYPE OF WORK (Check) : NEW WELL❑ DEEPEN,❑ RECONDITION ❑ DESTRUCTION❑ W <br /> WELL CHLORINATION C3 WELL. ABANDONMENT a OTHER 0 � <br /> PUMP INSTALLATION [5i PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCEFTO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> e 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 <br /> _ Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP : (Estate 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 i.n accordanc <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 INSP -G71W PRI TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ' <br /> IGNE - fLE: <br /> DATE: <br /> R LOT PL N REVERSE IDE <br /> i FOR DEPARTMENT USE ONLY 4' <br /> t PHASE I <br /> APPLICATION ACCEPTED BY DATE / 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II -GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE. INSPECTION BY <br /> , :... .. 1 78�2M <br /> FW ]a7G, Doti 1'9-77 <br />