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+ l• <br /> SAN JOAQUIN LUCAL -HLALI H DIS 1 K1C I <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205' Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-2-7--7,f", <br /> This Permit Ex fres 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 /> R and/br. install the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance. No. 1.862 and the Rules and Regulations of the. San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ;. �,� CITY/TOWN <br /> a <br /> Owner's Name Phone `7e- r <br /> , Address Ci ty <br /> Contractor's Name License# d Phone <br /> IS CERTIFICATE OF WORKMAN'S COM PENSATIO� TH RANCE ON FILE WITH SJLHD? YES t NO <br /> TYPE OF WORK (Check) : NEW WELL, DEEPEN ❑ RECONDITION (] - DESTRUCTION[) <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER# <br /> PUMP INSTALLATION ❑ PUMP REPAIR 0 PUMP REPLACEMENT Q OC <br /> DISTANCE TO NEAREST: SEPTIC TANK So * SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD SoA- 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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 12 —' <br /> Cathodic Protection Rotary Type of Grout y, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> n Type of Pump. H.P. <br /> PUMP REPLACEMENT: ❑State Work Done... <br /> PUMP REPAIR: ❑State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter �' ___ <br /> f Approximate Depth <br /> Describe Material and Proce ure ' ._� <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 Regulati'EWs' of t>ie 'San Joaquin Local <br /> Health District. Home owner or licensed agent' s signatur'e..certifies the following: <br /> 4 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. " E <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ANDA FINAL INSPECTION. _ <br /> SIGNED r-� TITLE: DATE: <5 <br /> (DRAW PLT L N ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> A In <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE T-/ ') INSPECTION •BY_3 _, , . .. DAT£7�/�"� ' <br /> ' <br /> ,EH -1426 !- Rev. 12-77 <br />