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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601' E. Hazelton Ave. , Stockton, CA 95205 Permit No.r12, ,5 <br /> � Telephone;p (209) 466-6781 <br /> APPLICATION FOR WELL CO�E�TRUCTION OR PUMP PERMIT Datq.rIssued ,� -� <br /> This Permit Ex pires 1 Year From Date Issued V ',O- <br /> Complete In Triplicate <br /> Application is hereby made to; the San Joaquin Local Health..District for a permit to cons irutt <br /> and/or install the work her described. This application- is made- in. compli.ance with San' <br /> ,oaQ,,in .County Ordinance No. 11862 and the Rules- and Regulations. of the .San. Joaquin Local -Hea'1 h <br /> District. <br /> EXACT STREET ADDRESS ` <br /> 0. CUaCG r� � - yYJ <br /> o F, - t' 4 ITY/TOWN_ VU(Y.Ll1I�iJ <br /> Owner' s Name <br /> hone <br /> Address / 22 City . <br /> Contractor's Name f -- <br /> i nse# Phone <br /> IS CERTIFICATE 'OF WORKfMAN'S OMPENSATION I'NSURAINQ, Oil F TN SJLHD? YES ti0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION C] .� <br /> WELL CHL INATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION E] PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC .TANKSEWER, LI.NES -- -- PIT­PRIVY — -•—� <br /> _. SEWAGE- DISPO.SALN-FI ELD\- CESSPOOL/SEEPAGE PIT , OTHER <br /> F PROPERTY LINE -, PRIVATE DOMESTIC/WELL i PUBLIC DOMESTIC WELL <br /> INTENDED USE TY.PE,.'OF,..WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation # <br /> —Domestic/private Drilled Dia. of Well Casing f� <br /> Domestic/public Driven :,..Gauge of Casing ._ <br /> Irrigation ' `Gravel Pack Depth of Grout Sea — <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _Other Other Information ' <br /> Geophysical; Surface Seal Installed by: € <br /> PUMP INSTALLATION:; Contractor <br /> #,�7 Type of Pump <br /> PUMP REPLACEMENT: Q 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 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 INSPECTION PRIOR GROUTING, AND AT L� INSPECTION. <br /> SIGNED <br /> 1 ITLE: s DATE: % <br /> ` DR W LOT ON REVERSE SIDE <br /> FOR DEPA MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: dr=' DATE . <br /> _ r 1 <br /> PHASE II GROUT I ECTION Zz <br /> PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE j <br /> INSPECTION 8Y DATE -7 <br />:H 1426 Rev. 12-77 , <br />