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SAN -JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFF?C1= U5E: 1601 E. Hazelton- Ave. , Stockton, CA 95205 Permit No. _ <br /> - Telephone: ' (209) -465-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires .l 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 zpplication is made in compliance with San <br /> 4oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local .Health <br /> District. ( s <br /> EXACT STRE£T. ADDRESS ' J CITY/TOWN <br /> Owner' s Name Phone <br /> Address ® City <br /> Contractor's Name . Li ceeseif Phone,, Z 4A /_ _! <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'l VitUR`ANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL C DEEPEN 0 RECONDITION ® DESTRUCTION[j <br /> WELL CHLORINATION0 WELL ABANDONMENT E3 OTHER ( O <br /> PUMP INSTALLATION [PUMP REPAIR 0 PUMP REPLACEMENT 0 <br /> S <br /> DISTANCE TO NEAREST: 'SEPTI-GiTANK WER LIN-ES- PIT PRIV-Y.---- � <br /> SEWAGE :;DIS OSAD,,,f' CESSPOOL/SEEPAGE PIT _ OTHER <br /> ' PROPERTY LINE -. PRIVATP DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 1 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toole--- Di-a-i-of Wel 1 .Excavat.i-on - ' ' <br /> ::�omestic/private i Drilled Dia. of Well 'Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pac-k Depth of Grout Seal <br /> Cathodic Protection �`tary Type of Grout �°� <br /> Disposal Other �'� Other Information <br /> Geophysical Surface Seal Instal ed by: f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done , <br /> PUMP REPAIR: El State Work Done <br /> f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure T <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 i <br />' Health District. Home owner or licensed agent' s signature certifies the following: I <br /> "I certify that in the performance of,the work .for which this permit -is issued, -I--shall <br /> , <br /> not employ any person in -,iuch manner -as,-to' become subject t`o' Wbrkman-i's p nsation <br /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />„SIGNED TITLE: DATE: <br /> 1i (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� DATE - ~7Y. <br /> APPLICATION ACCEPTED BY , <br />''ADDITIONAL COMMENTS: ft <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE r. INSPECTION BY d DATE <br />�rii IAnc n_.. In 7 / 1 /78 2M <br />