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Cal- /0 18 SAN JOA QUIN LOCAL HEALTH DISTRiCI- <br /> FFICE USE: 1601 E. Hazelton Ave': ,. Stockton, CA 95205 Permit No.,7s _Jss j <br /> Telephone: (209) 466-6781 <br /> h <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ _ 8' <br /> { This Permit Expires 1 .Year From Date Issued <br /> Complete,:In Triplicate - <br /> Application <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 -7(1- CITY/TOWN-- � <br /> Owner's Name! T` / Phone <br /> t <br /> Address City, <br /> Contractor's . Name Li cense# /,J�3 ZISS 'Phone F 76 <br /> IS CERTIFICATE OF WORKMAN"S COM NSATIOiI INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN C], RECONDITION Q DESTRUCTION <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 <br /> .,PUMP INSTALLATION PUMP REPAIR O PUMP REPLACEMENT Q G <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r <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 Drilled Dia. of Well Casing <br /> !_Domestic/public Driven Gauge of Casing <br /> 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 /> ;I PUMP REPLACEMENT: State Work Done <br /> f PUMP: C$State Work Done *' <br /> s DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> ' I hereby certify that I have prepared this application and that the work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws, and Rules- and Regulations of the San Joaquin Loca' <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 WDrkman 's Compensation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECT P TOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TLE: DATE: d 3/ <br /> W PLOT PLAW ON REVERSE ID <br /> FOR DEPARTMEN7 USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL //4/7s - <br /> COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE kIIJINAL INSPECTION <br /> ` INSPECTION BY DATE INSPECTION BY DATE b �� <br /> 4H 1426 Rev. 12-77 -- 1/_78. 2M <br />