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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> EQR OFFICE USE: 1601 E. Hazelton Ave. , Stockton; CA 95205 Permit No. 1jr-5` / <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT_ Date Issued y'���d/ <br /> This Permit Ex ires '.I 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 workherein described: This application is made in compliance with San <br /> ,'oaquin County Ordinance No . 1862 and the pules and Regulations of the San Joaquin cal Health l <br /> District. 1 <br /> EXACT STREET< ADCom/ CITY// <br /> Owner's Name Phone 1 ! <br /> Address City <br /> Contractor' s Name Licens Phone <br /> W' ; <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"I INSURANCE ON FILE WITH SJLHD? YES � NO <br /> TYPE OF WORK (Check) : . NEW WELL - DEEPEN ❑� RECONDITION ❑ DESTRUCTIONED W <br /> WELL CHLORINATION Q WELL ABANDONMENT ® OTHER 0 G, + <br /> PUMP INSTALLATION D,--' PUMP 'REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL MELD CESSPOOL/S PIT OTHER <br /> PROPERTY LINE/V PRIVATE DOMESTIC WELLUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI S-7 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> t7"-Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation T Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1/totary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b i <br /> PUMP INSTALLATION: -Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ]State Work Done <br /> PUMP REPAIR: CD tate Work Don <br /> DESTRUCTION OF WELL: ,-\ Well Diameter d Approximate Depth--­ <br /> Describe <br /> th — <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 /> "I certify that _in the performance of, the. work for which this permit` is issued, I shall <br /> not employ any person' in such.madner 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 ki— TITLE: .,, _.�� DATE: -31, 71 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. .. <br /> ADDITIONAL COMMENTS : <br /> PHEhJI GROUT INSPECTION y PHASE, IT INAL INSPECTION <br /> INSPECTION BY DATE- INSPECTION BY DATE 8 <br />