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SAN MAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.TZg_1,V,7/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued-24- <br /> This Permit Expires 1 Year From Date Issued <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 /> Joa(iuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin ,Local Health <br /> District. _ <br /> EXACT STREET ADDRESS ��Sj CITY/TOWN Mir 1c0. <br /> Owner' s Named yh FPhone <br /> Address_ - )444,-r._._.. City <br /> Contractor's Name Ze L� License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO`! INSURA?ECE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT C] 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 Surface Seal Installed by: 6VQ21ey-- <br /> PUMP INSTALLATION: Contractor Se <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 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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. r !� <br /> SIGNED or -� TITLE: Q f(} dUEQ - DATE: <br /> (DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 1 /78 �'2M <br />