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FFICE USE 4 SAN JOAQUIN LOCAL HEALTH DISTRln <br /> 1601 E. Hazelton Ave. , .Stockton, CA --!5205 Permit. No. 72 <br /> Telephone: (209) .4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date, Issued <br /> .(Complete 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 in compliance with San <br /> Joaquin County Ordinance No. 1862. and the Rules and Regulations of the San Joaquin local Health <br /> District. <br /> f EXACT STREET. ADDRESS <br /> S6 CITY/TOWN <br /> i Owner's Name Phone <br /> f Address <br /> ell _C. •t� Yr_ <br /> contractor's Nam Li ense# 741_T}ione <br /> IS CERTIFICATE OF WORK�IAN'S CO"OPEN TTHr, INSURA"lCE ON FILE WITH SJLHD? YES 0 <br /> TYPE OF WORK .(Check) : NEW WELL L DEEPEN 0 RECONDITION ® DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 . <br /> PUMP INSTALLATION C] PUMP .REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> SEWAGE' DISPOSAL.FIELD CE_S OL/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 We 1 Excavation o <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ._Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal Other Other Information <br /> Geophysical I �- Surface Seal Insfalled b <br /> PUMP INSTALLATION: Contractor C <br /> Type of, Pump <br /> PUMP REPLACEMENT: <br /> State Work Done... .,._ -- � <br /> [State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material an Froceaure Approximate Depth <br /> i l <br /> I hereby certify that I have prepared this application and that theworkwill be done in accordane C <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 <br /> ,not employ an permit is issued, I shall <br /> p y y person in such man <br /> Taws of 'California.° ner as to become subject to Workman's Compensation <br /> WILL CA FORA GROUT INS . T N I TO GROUTING AND A FINAL INSPECTION. <br /> N' <br /> TLE: }� DATE... <br /> L T L REVERSE .SI E <br />'RASE I I# OR DE ART _NT USE 0 Y <br /> PP.LICl�TION ACCEPTED BYi ,cam <br /> DOITIONAL COMMENTS: A1/7'50 <br /> PHASE II GROUT INSPECTION <br /> ISPECTION BY DATE PH E INSPECTION <br /> INSPECTION BY DATE <br /> A 14 7F Paw Q/7R — <br />