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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P�JFFIrr USE: 1601 E. Hazelton Ave-.-;- Stockton, CA 95205 Permit No. <br /> _ Telephone: (209) ,466-6783. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> ('Complete In Tr' ipl'icate) <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 N6. 1862 and- the Rules and' Regulations of the San Joaquin Local' Health <br /> District. <br /> EXACT STREET ADDRESS a <br /> &642,n ` ii CITY/TOWN 1t }t> <br /> Owner's Name <br /> Phone - } <br /> Address <br /> . <br /> Contractor's Name A' License /0. Phones ' �7 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ONEFILE WITH,SJLHD? YES. <br /> TYPE OF WORK (Check) : NEW.,WELL L,,, DEEPEN ❑ RECONDITION 0 DESTRUCTI'DWEI <br /> HL <br /> WELL CORINATION j�FWELL ABANDONMENT Q OTHER Ems\' *, <br /> PUMP' INSTALLATION REPAIR .SMF REP�ACwE'MENT W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , k, PIT PRIVY <br /> SEWAGE DISPOSA! TIELD CESSPOOL/SEEPAOE, PIT OTHER- - <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WE—L�� <br /> —-INTENDED USE <br /> TYPE OF WELL., S CONSTRUCTION SPECIFICATION$+I'��F <br /> Indittr.l.al. Cable Tool �a , � Dia: oaf Well Excavation <br /> _Domestic/private Drilled D7a. �of Well Casing <br /> Domestic/publ-ie Driven Gauge� of Casing <br /> Irrigation Grayel Pack D2pth,of Grout Sea <br /> ___. Cathodid 'Protection Rotary Type bf Grout �. � - • <br /> sposal = Other <br /> Othertilnformation " <br /> Geophysical _ �,-F_____ --_ _ rface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _- <br /> PUMP REPLACEMENT: W State Work Done <br /> PUMP REPAIR v a <br /> - QState\Work`Done.. <br /> ' <br /> DESTRUCTION O.F'WELL- Well Diameter: �,CS Approximate Depth <br /> Descri'be'NlaterTa -and Proce ure <br /> I hereby certify that .I have prepared this application and that the work will be done in accordancl <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of -the San Joaquin-Local <br /> Health ,Di.strict. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for -which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation. <br /> laws of' California. " <br /> I WILL CALL A GROUT NSP CTION PRIOR TO GROUTING- AND A FINAL INSPECTION. <br /> SIGNED TITu--:a_..- DATE:_ =� `717 <br /> DR W PLOT L-.N- ON REVER SIDE <br /> PHA- �� OR DEPAR USE ONLY <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL•- COMMENTS: DATE 3 <br /> PHASE iI GROUT INSPECTION PHASE IIINA! INSPECTION <br /> INSPECTION BY DATE f INSPECTION BYA/ DATE <br /> EH 14 26 Rev. 9/7$ 78 -2M <br />