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r5AN JOAQUIN LOCAL HLALIH U1JIK1Lf <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 V 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued - 12- 7 <br /> This Permit Expires 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> 'district. pp <br /> EXACT STREET ADDRESS] <br /> CITY/TOWNA."..,2 <br /> Owner's Name '.�, �li -- Phone_ g,�/- VSI'Z -- <br /> Address City <br /> Contractor' s Name --a '�1, . P�.� „ . Li cense#/i�3 73 Phone <br /> ?S CERTIFICATE OF WORKMAN'S COFiPENSATIOiI IINSURANC£ ON FILE WITH SJLHD? YES 140 <br /> TYPE OF WORK (Check") :— NEW WELL Q ' DEEPEN-0 RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ PIT PRIVY <br /> 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 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 /> PUMP REPLACEMENT: State Work Donee&,1 fW &zt. <br /> PUMP REPAIR: ❑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 accordant( <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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE: DATE: <br /> (DRAW PLOT PLAN ON REVERSESIDE) <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE Jr 2lv 7Z <br /> ADDITIONAL COMMENTS: .zz--t44--1 Z��4 <br /> PHASE II GROUT INSPECTION PHA$ENJJCffINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ��-�� <br /> EH 1426 Rev. 12-77 1/78 _2M <br />