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SAN JOAQUIN LOCAL HEALTH DISTRICT : <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permit No. 7g-6o6 <br /> Telephone: (209) 4'66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate /Va S .-7?.'720 <br /> Application is hereby made to the: San Joaquin Local Health District for a�ermit to construct <br /> and/or install the work herein described. This application is made in .compliance with San <br /> 'oaQu i n County Ordinance Nlo. {1862 and. the ,R�+les -and Regulations of .the. San Joaquin Local Health <br /> District. /5-ds- S- IT <br /> EXACT STREET ADDRESS - CITY/TOWN <br /> Owner's Name Phone S o.3 <br /> Address City -c <br /> Contractor's Name 11 License#�r�,P/� Phone <br /> k <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATInM IPJS A*•SCE ON FILE WITH SJLHD? YES NO <br />, TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 54'+ CESSPOOL/SEEPAGE PIT OTHER `4 <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 •• ,N; , <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 b <br /> PUMP INSTALLATION: Contractor <br /> Type o'f Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <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 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 /> a <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 GRO T INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. { <br /> SIGNED ` TITLE: DATE: <br /> DR W PLT L N ON REVERSE SIDE <br /> !i FOR DFPARTMENTUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> 411177 <br />, ADDITIONAL COMMENTS: 67 <br /> PHASE II GROUT INSPECTION' PHASE III FINAL INSPECTION / <br /> INSPECTION BY DATE INSPECTION BY DATE 41X191-2 <br /> 'EH 1426 RAv- 19-77 ������ 0?l6- 91/78 2M <br />