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` SAN JOAQUIN LOCAL HEALYH DIS1-RIC-1 <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 l <br /> Telephone: (209) 466-678.1 er <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued -dl-7 <br /> This Ex fires 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 applicati.on -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 /> ;,2R <br /> EXACT STREET ADDRESS,Ail , , /T! � <br /> y Owners Name .�_ Phone —/r <br /> S't as N <br /> Address / �� �, City <br /> " - — S!5 <br /> Contractor's Name's at2b Will ��ir� _.l ,z "�-License# Phone <br /> - <br /> IS CERTI.FICATE. OF.-WORKMAN'S COMPENSATION INSURANCE ON-FILE WITH. SJ.LHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0RECONDITION ❑ DESTRUCTION[) � <br /> I WELL CHLORINA DEEPEN� ELL' ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑' -PUMP REPAIR❑ PUMP REPLACEMENT L7 <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL' FIELD _ CESSPOOL/SEEPA�E PIT �_ OTHER <br /> PROPERTY LIN066 PRIVATE DOMESTIC WELL �UBLIC DOMESTIC WELL --- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toole Dia. of Well .Excavation <br /> M Domestic/private .. DrilledDia. of Well CasingV ,# Calzmq <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 <br /> Type of Pump — H.P. <br /> i'. I <br /> PUMP REPLACEMENT: ❑State. Work Done <br /> PUMP REPAIR: ❑State Work Done <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 WDrkman's Compensation <br /> laws of California." <br /> I WILL CAU FOR A GROUT XNSP CTI-0 PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1 . TITLE: DATE: <br /> DRAW PLT PEAN ON REVERS DE <br /> FO DEPARTMENT USE,ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY F -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ' III FINAL INSPECTION <br /> INSPECTION BY DATE = '-A-.'INSPECTION.INSPECTION BY DATE <br /> EH 142F Rev- 12-77 w 1/78 2M <br />