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SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> FOR. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 1 3 <br /> Telephone: (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM " a , Issued <br /> This Permit Ex ires 1 Year ,Fro ,te ssued <br /> Complete In Tri.pl i c e <br /> Application is hereby made to the San Joaquin Local Heal h D' .ict for a. permit to construct <br /> and/or install the work he"rein described. This applica is made in compliance with San <br /> Joaou7n County Ordinance No. 1862 and the Rules and Regulations of the San, JJoa/quin Local Hea14 <br /> EXACT STREET ADDRESS a5� <br /> ' ir1 - . ���� S� ! ITY/TOWN _ <br /> Owner's Name Phone �" <br /> Address <br /> City <br /> Contractor's Name -'�- <br /> Yf�' License# Phone�s;j/�,� , <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL f DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION L PUMP REPAIR❑ PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD_ CESSPOOL/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 /> X Domestic/private Drilled Dia. of Well Casing " 6 <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation _Gravel Pack Depth of Grout Seal 4 <br /> Cathodic Protection _Rotary Type of Grout <br /> — APIP <br /> Disposal Other Other- Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Amate. ial <br /> 1 H,P. f <br /> PUMP REPLACEMENT: Q Stateone , <br /> PUMP REPAIR: Q Stateo�DESTRUCTION OF LL: We11 `Dia Approximate Depth <br /> Describeand Procedure <br /> I hereby certify 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 NSPECTION PRIORTO GROUTING AND A -FIAL INSPECTION. <br /> SIGNEDTITLE: DATE: <br /> PDRAW PLT L ON REVERSE SIDE <br /> FOR DEMMMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE — - <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />_H 1426 Rev. 12-77 T.�_ -� ,'`I Fsr— <br />