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v <br /> SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave.., Stockton, CA 95205 Permit No, <br /> Telephone: {209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedf?-)_ <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 /> Joao-jin County Ordinance No. 1862 and the -Rules and Regulations of the San Joaquin Local . Health <br /> District. <br /> EXACT .STREET ADDRESS p 0 ` CITY/TOWN <br /> Owner' s Name &Jee.r Phone_&3,; —o9&P( <br /> Address.. �t .tti9 City <br /> Contractor' s Name ` License#�. Phone '= C j <br /> IS CERTIFICATE OF WORKMAN'S 'COMPENSATIO'S INSURANCE ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT EJ OTHER 0 <br /> PUMP INSTALLATION CM PUMP REPAIR❑ PUMP REPLACEMENT ❑ LM <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <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 b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Iy� <br /> PUMP REPLACEMENT: [] State Work <br /> PUMP REPAIR: C7 State Work Done <br /> DESTRUCTION OF WELL.: Well -Diameter Approximate Depth <br /> Describe Material and Proce ure <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 C R A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. I <br /> SIG TITLE: DATE: c?3-- <br /> / 78 <br /> DRAW PLOT PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATK-' =7 <br /> ADDITIONAL COMMENTS : 9 �� �� Z:42� <br /> PHASE II GROUT INSPECTION PHASE III FINAL -IPSPECTION <br /> INSPECTION BY DATE INSPECTION <br />:LdIA7C n_.. �n -7-7 _ <br />