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SAN JOAQUIN LOCAL..HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton. Ave. , Stockton, CA 95205 Permit No. 7S .z <br /> ._ Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3-��) <br /> This Permit Expires Z' Year `From Date Issued <br /> ,k. 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 with San <br /> E4oanuin County Ordinance Nu. J1862 and the. Rules and Regulations of the San Joaquin Local Health <br /> District. �. l <br /> EXACT STREET ADDRESS3 �" c<1ca. �•,�I CITY/TOWN <1i4.A/7 <br /> Owner's Name Name } Phone <br /> Address .— City <br /> Contractor' s Name -v License# Phone <br /> IS CERTIFICATE OF WORKMAN'S 6MPENSATIO"J INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : 'NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> i` WELL CHLORINATION p WELL ABANDONMENT ❑ OTHER ❑ <br /> 'PUMP II ISTALLATION E4 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />( DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD 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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other � � Other Information <br /> Geophysical a Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />' PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done . . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce�dui^e­ - <br /> i <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 FOEJ GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - _ '..--� <br /> r. ThTLE-,:-0��.►�-� -- _ DATE: -7 ':�� <br /> RAW T PL N ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE`ONLYq ._ <br /> APPLICATION ACCEPTED BY f <br /> DATE 3�le 79 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSFECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> , -16-- <br /> EH 1426 Rev_ 12-77 1 17A - 9M <br />