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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No._.2q- 65-1 <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued z0-79 <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 N 1862 andthe Rules and Regulations of the San Joaquin Local Health <br /> o. <br /> District. 1096-_ <br /> EXACT STREET ADDRESS <br /> CITY/TOWN ��/i <br /> Owner's Name f. yr Y Phone_ <br /> Address p eCity <br /> Contractor's Name i �� ' License , Phone <br /> .IS CERTIFICATE OF WORKMAN'S COMPENSATION INSU ANCE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL 93-' DEEPEN 0 RECONDITION { DESTRUCTION[ O` <br /> WELL CHLORINATION 0 WELL ABANDONMENT C3 OTHER 0 <br /> PUMP INSTALLATION ffr' PUMP REPAIR D PUMP REPLACEMENT [ <br /> DISTANCE TO NEAREST: SEPTIC TANK_ZP01'­SEWER LINES . LYS PIT PRIVY �-- <br /> SEWAGE DISPOS�,�IELD — C�/5 PAGE PITIED BOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DDIESTIC WELI ._.� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I dustrial Cable Tool Dia. of Wel Excavation <br /> i/�omestic/private Frilled Dia. of Well Casing 's2 <br /> Domestic/public Driven Gauge of Casing G. <br /> Irrigation Gravel Pack Depth of Grout Seal_Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical / Surface Seal Instaled <br /> PUMP INSTALLATION: Contractor s� <br /> Type of Pump-_ H.P. l' <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: Q State 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 -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. <br /> I WILL CALL FOR A GROUT _I.NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE: I DATE: <br /> D PL L N ON REVERS SIDE) - <br /> DEPARTMENT <br /> IDEDEPAR MEN USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY9O e-� DATE <br /> e<li 4, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C DATE k2,o17,9 <br /> EH 14 26 Rev. 9/78 —_ �- <br /> . _ .. . 9/18 2M <br />