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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued V' <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. <br /> EXACT STREET ADDRESS r; &I CITY/TOWN /ro dj <br /> Owner'.s Name Phone _ c_ <br /> Address-?V'17 ��/' <br /> r'" Ci'tY--' r <br /> Contractor's Name , f, .JsLicense# Phone <br /> IS CERTIFICATE Of WORKMAN'S COMPEN ATIO"J INSURA"SCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION [n DESTRUCTIONEJ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER F-:1 <br /> PUMP INSTALLATION 51— PUMP REPAIR❑ PUMP REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1d7 SEWER LINES�_'PIT PRIVY <br /> SEWAGE DISPOSAL FIELD s- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE `: PRIVA to <br /> WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ^4.,,-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 " , IV d j4� r, o2 al, r <br /> Type of Pump <br /> H.P. - <br /> PUMP REPLACEMENT: F]State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an-d 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 /> "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 /> SIGNED TITLE: DATE: <br /> (DRAW PLOT PLAN ON RE ERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYA 9LDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY "7P <br /> EH 1426.. Rev. 12-77 1 /78 2M <br />