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SAN JOAQUIN LOCAL HEALTH DISTRICT Permit No. ' <br /> OFFICEFOR USE: 1601 E. Hazelton.Ave. , Stockton, CA 95205 �--- <br /> Telephone: (209) . 466-6781 Date Issued5 Jyr�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires . l Year %From Date Issued. <br /> Complete In Triplicate <br /> A l icati on is hereby made to the San Joaquin `Lo.cal �Heal.th -District for a permit r anceto const <br /> san ct <br /> QP <br /> and/or install the work herein described. " This application 1s made � <br /> Joaquin County Ordinance No. 1862 ` and the Rules..and Regulations of the San Joaquin Local Health <br /> District. 3 <br /> CITY/TOWN <br /> F T ADDRESS <br /> EXACT'STREE <br /> Phone <br /> Owner' s Name /i1 C� x <br /> City <br /> Address _ <br /> License# Phone <br /> Contractor's Name <br /> 'S CERTIFICATE OF WORKMAN'S COMIPENSATION INSURA"fCE ON FILE 1IITH SJLHD? YES <br /> X10 <br /> c� <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ElWELLRECONDITION <br /> ABANDONMEN� OTHER Q DESTRUCTION,[*— wP%GIS <br /> - - <br /> WELL CHLORINATION Q <br /> PUMP INSTALLATION Q PUMP REPAIR Q PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST:\, SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> WELL <br /> -- - PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC—DOMESTIC <br /> INTENDED USEY TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> v <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 Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:. ] State Work Done <br /> � PUMP REPAIR: � • 4 5, ❑State Work Done _ --, _ k- JJ <br /> DESTRUCTION OF WELL: Well Diameter . l� oximate Depth�rSa <br /> A pr <br /> Describ Material and yroce ure <br /> i I hereby certify that I haven prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State�:,L-aws , 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 Ito'-Workman' s Compensation <br /> laws f aIiforn ' Is <br /> P <br /> I WILL OR A GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPEC ION. <br /> - - <br /> DATE: 3 <br /> SIGNED TITLE: <br /> DR W PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY p� <br /> PHASE I _ DATE 6— �70 <br /> 22_2� - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: —"S I z .7. ' " <br /> PHASE II GROUT INSP TION PHASE 411 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - -1 <br /> 78 2Y <br /> rw 1 A9A poll 19-77 <br />