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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,.-tOFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone,: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT�f Date Issued 7—lo-79 <br /> (Complete In Triplicate) PO1c <br /> ,Application is hereby made to the San Joaquin Local Health District �"`a 'permit o 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 A ESS r CITY/TOWN �' . <br /> Owner's Name r rf Phone <br /> Address City <br /> Contractor's Name y' ,License Phone 2z <br /> .IS CERTIFICATE OF WORKMAN'S COMPENSATION INS ANN F ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION C3 <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 <br /> / ST PI I f PU RE IR-❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTI TANK l` WER 'LINES&0 PIT PRIVY -�—. <br /> SEWA E DISPOS ELD CESSP L/SEEPAGE PIT <br /> PROPERTY LINE PRIVATE DOMESTIC WELLS PUBLI�Q ESTICRWELL 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> —Domest'ic/private �I lled Dia. of Well Casing r, r <br /> Domestic/public Driven Gauge of Casing ,fnc <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection �otary Type of Grout f <br /> Disposal Other Other Information <br /> " <br /> Geophysical Surface Seal_ Installed_ <br /> ed by,:._ <br /> PUMP INSTALLATION: Contractor ,� <br /> Type of Pump , ' H. f <br /> PUMP -REPLACEMENT: ❑State Work Done 10 <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an-& 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 GROUT NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: j, DATE: <br /> (DRAWPLO77—LU ON REVERSv REVERSSIKJ <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> PPLICATION ACCEPTED BYr O� DATE <br /> ADDITIONAL COMMENTS: - , <br /> PHAS ��I GROUT INSPECTI N PHASF III FINAL INSPECTION <br /> INSPECTION BY ."(/f , �,f, DATE__7/ 1,tl INSPECTION BY ( � 25.7 <br /> E 14 26 Rev. 9/7$ _ E�� f 917.8 2 <br />