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o 4 ' . ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT Permit No. 1/�S� <br /> OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, CA 95205 <br /> M, Telephone: - (209) 466-6781 <br /> E• APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> (Eomplete In Triplicate). b <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 d3 • A) �A CITY/TOWN <br /> !M' Phone <br /> Owner's Name " <br /> Ad' _ -.City. a . <br /> 1C License# 32�Lsf'Phone� _"j,� G?� <br /> ' Contractor's Name _ �., _ — <br /> I$! CERTIFICATE -OF WORKMAN'S �C mP'ENSATION INSURANCE' ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW 'WELL 0 DEEPS [I RECONDITION [] DESTRUCTION[n. . <br /> !i WELL CHLORINATION Q WELL ABANDONMENT 0 - OTHER 0 - — <br /> PUMP INSTALLATION CI PUMP REPAIR® PUMP REPLACEMENT C '' <br /> DUTANCE TO NEAREST: SEPTIC TANK SEWER L"INES_ ._ PIT PRIVY <br /> C SEWAGE DISPOSAL FIELD CE5SPA/SEEPAGE PIS- 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 /> M. . Domestic/private Drilled Dia. of Well Casing, <br /> d 7- Domestic/public ; Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection ; . Rotary Type of Grout <br /> Disposal 'Other Other Information <br /> t Geophysical T Surface 5ea1 Installed b <br /> PLfMP INSTALLATION: Contractor <br /> o_ <br /> Type lof Pump H.P. <br /> PUMP REPLACEMENT: 7JState Work Done - <br /> PUMP REPAIR: ®State Work Done xme � <br /> _D�STRUC-TI-ON'OF-WEL-L:-" Well' Diameter T T Approximate-Depth <br /> Describe Materia an roce ure <br /> Ihereby certify that I •have prepared this application and that the work will be' done in accordani <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 Workman's Compensation <br /> laws of California. <br /> � I&WILL CALL FOR A GROUT INSPECTIO PRIOR TO GROUTING AND A'FINAL: INSPECTION. <br /> F. <br /> ► SIGNS TITLE: DATE: �. <br /> �,. - . (DRAW _PLUT TLAN ON REVERSE SIDE) <br /> FOR ARTMEN USE ONLY <br /> PHASE I DATE C <br /> APPLICATION ACCEPTED BY57, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTiINSPECTI.ON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY er ATE 3 IZ. 2 <br /> E} M=14 26 Rev. 9/78 .. - _ 9/78 2M <br />