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Co L-io AV 14,� SAN JOAQUIN LOCAL HEALTH DISTRICT -- - <br /> r ---I <br /> _EQR OFFICE 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 7- -7 <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 Q S CITY/TOWN <br /> Owner's Name Ii1, 11 a Iv de e)✓ Phone <br /> Address J A A City Z) <br /> Contractor' s Name License# 2 'Phone <br /> TS CERTIFICATE OF WORK'1AN'S C01M NSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p,, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONSPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ -�— <br /> Domestic/private Drilled Dia. of Well Casingy <br /> Domestic/public Driven Gauge of Casing <br /> y- 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. d Q <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPA?R: X]State Work Done `4 <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 accordan <br /> with Sar, Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 GROUT INSPE N R OR G OUTING AND A FINAL INSPECTION. <br /> SIGNED 4 TLE: i^ DATE: f� <br /> DR W LO PL N ON REVERSE SIDE <br /> FOR DEPARTME T USE ONLY <br /> PHASE �1�-29?9 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE I FIN L INSPECTION <br /> INSPECTION BY DATE INSPECTION DAT <br /> LH 14 26 Rev. 9/78 /79 2M <br />