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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - 7P <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 CITY/TORN <br /> Owner's NamePhone <br /> Address i_4444,tdnz e14 City <br /> Contractor's Namedeaa� License 7 honeQ' 13 iiZ13 <br /> IS CERTIFICATE OF WORKMAN'S M.MENSFl ON INSURANCE ON FILE WITH-SJLHD? YES NO. <br /> TYPE OF WORK (Check) : NEW WELL ft' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ �� ? <br /> WELL CHLaRINATION 0 WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION M PUMP REPAIR❑, PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES O PIT PRIVY ' <br /> SEWAGE DISPOSAL-FIELD SAL FIELD CESSP OL/SEEPAGE .PIT OTHER _T) ' <br /> PROPERTY LINE' PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WE L <br /> INTENDED USE TYPE OF WELL_ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation N a <br /> _:i�Domestic/private Drilled Dia. of Well Casing <br /> g �b <br /> Domestic/public Driven Gauge of Casin ' <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection <br /> Rotary otary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Sea] ' Insta ed <br /> PUMP INSTALLATION.: Contractor "1 <br /> k Type.. of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> 'PUMP REPAIR: ❑State Work Done Al <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�performanc-e_ 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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �f <br /> D W PLOT PL N ON REVERSE-S-IDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> PPS LIGATION ACCEPTED BY V2&/,pe- DATE / .- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC ION _ PHASE III FINAL INSPECTION <br /> INSPECTION BYi' ._ DATE ro-XJINSPECTION BY '�/Z�� DATE ^ <br /> EH 14 26 Rev. 9/78 78 -2M <br />