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+ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFI E USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 9�i,2-/ <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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. <br /> 'EXACT STREET ADDRESS ohne ;,�K&O 1&02 CITY(TOWN <br /> +Owner's Name ,�c �/;�/� Phone_ <br />:Addresst'7?' ly n '? City _ <br /> Contractor's Name f- License# l —Phone 544 ?6 <br /> IS CERTIFICATE OF WORKMAN'S COMPEN TION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN Q RECONDITION Q DESTRUCTION_rl_ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ED <br /> PUMP INSTALLATION CI PUMP REPAIR09 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS OOL/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 Sea <br /> Cathodic Protection Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: I5KState Work Done c�G�._...�e..�, ,cry ,,� /-t a <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.CAL1. FOR A GROUT INSPECTIO IOR OUTING AND A FINAL INSPECTION. <br /> SIGNE DATE: <br /> PLOT PLANON RVERSES DE <br /> PHASE I FOR DEPARTMENT SE ONLY <br /> PPS LICATION ACCEPTED BY DATE 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 _� - / 2M <br />