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F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE 1601 E. HazeltonAve. , Stockton, CA 95205 Permit No.7 9-u'7,& <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Date Issued �7 9 <br /> 'O(Complete .In Trip1.fcate). <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 in compliance with San <br /> Joaquin .County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local -Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN ' <br /> Owner's Name Phone �7— 4X/ ...� -_ <br /> Address City <br /> Contractor's Name License#/6 x.373 Phone ° 3 '� <br /> tS CERTIFICATE -OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELLtg DEEPEN [I RECONDITION DESTRUCTION <br /> a WELL_CHLORINAT-ION-�o- �---WEttf--,ABANDONMENT C�- 'OTHER - N' <br /> - PUMP INSTALLATION 24 PUMP REPAIR❑ PUMP REPLACEMENT [a ~ . <br /> DISTANCE TO NEAREST: SEPTIC ,;TANK � SEWER- LINES 1�.® __PIT PRIVY # �^ <br /> SEWAGE .DISPOSAL FIELD" Kc /­CESSPOOL/SEEPAGE PIT OTHER.. <br /> PROPERTY LINE - PRIVATE DOMESTIC W£LL -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF'WELL .-CONSTRUCTION SPECIFICATIONS-. <br /> Industrial Cable Tool Dia. of Well Excavation /� <br /> omestic/private Drill,ed._: Dia. of Well Casing Ir ` <br /> Domestic/public Driven .- -Gauge of Casing 1 / <br /> N Irrigation, Gravel Pack' Depth of Grout Sea i 10 <br /> Cathodic Protection _Rotary i7ype of Grout - ' <br /> ' * Disposal Other , k Other Information 3 <br /> Geophysical -- Surface .Seal Installed by: <br /> PUMP INSTALLATION:-, —�Contractor— <br /> Type of PumpH. . <br /> r <br /> PUMP REPLACEMENT: E]State Work Done_ <br />` PUMP REPAIR: Q State Work Done 3" <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 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. .. I <br />` I WILL CALL/9R GROUT SPECTION P R TO GROUTING AND k FINAL INSPECTION. <br /> SIGNED TITLE: DATE:' . <br /> _ PL ON REVERSE E t <br /> i r FOR DEPARTMENT USE ONLY f <br /> PHASE I <br /> PPLICATION ACCEPTED BY tv DATE <br /> ADDITIONAL COMMENTS: <br /> -,PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY . " � 13-. DATE- S-J`" �� INSPECTION BY DATE <br /> •g- <br /> EH 14 26 Rev. 9/7$ �,. _ R- <br />