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SAN JOAQUIN LOCAL HEALTH DISTRICT Permit No. S <br /> FF jjs '; 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> Telephone: (209) 466-6781 Date Issued 3- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (comp l ete In Triplicate) ;; <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made <br /> tin compliSan ance <br /> Local with <br /> San <br /> nealth <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations <br /> District. t CITY/TOWN _ " r3 4j <br /> EXACT, STREET ADDRESS ` <br /> Owner's' Name <br /> , � t Phone P " <br /> ' � � , . a � 1 City i <br /> Address R � r- - - <br />:Contractor's Name T #,, " (,-t #.''License# Phone <br /> IS CERTIFICATE OF WORKMAN'S CO""PENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL%0 DEEPEN ❑ RECONDITION ❑ DESTRUCTI N El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ <br /> PUMP INSTALLATION Ea PUMP REPAIR❑ PUMP REPLACEMENT [: <br /> i. DISTANCE TO NEAREST: SEPTIC TANK S 1 -#SEWER LINES PIT PRIVY <br /> SEWAGE DISPQSAL FIELD p{t_wCESS�OL/SEEPAGE PI�f— OTHER <br />' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC W LL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I ndUstri al ,�CCabl a Tool Dia. of Wel 1 Excavati on 24. <br /> Domestic/private Drilled Dia. of' Well Casing <br /> Domestic/public X Driven Gauge of Casing <br />� - Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other f <br /> Other Information <br /> Geophysical Surface Seal Insta ed b : t, <br /> PUMP INSTALLATION: Contractor H - <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> ' PESTRUCTION .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 San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loci <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. <br /> IGNEDv °: . 4 .. I< TITLE: . .,. DATE: <br /> --(DRAW -PLOT PL N ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I " <br /> � <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> IlSPECTION BY DATE INSPECTION BY DATE <br /> 9/78 - ..2M <br /> P44 ' 1A 99 Rate_ 9/7R <br />