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FFICE USE: SAN JOAQUIN LOCAL IIEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, CA. 95205 Permit No 7y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued—,/-.q <br /> (Complete Io Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons uct <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin Cuunty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN �1 <br /> Owner's Name - _ Phonelr-,-r,.A, <br /> Address 7y/ iWIIA�14'- <br /> City <br /> ractor's NameLicense# >�5 ,7,'PhoneIS ,.ERTIFICATE OFS COMP—ENSSAATION I"1SURA"1CF ON FILE WITH SJLHD? YES N0 <br /> TYPE OF WORK ;Check) : NEW WELL 0 DEEPEN❑ RECONDITION ❑ DESTR;ICTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ', OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK�iz_ SEWER LINES PIT PRIVY <br /> SEWAGE DISP SO AL FIELD CESS�bL/SEEPAGE PIS_ OTHER <br /> PROPERTY LINE - PRIVATE 7 FIESTIC WELL - PUBLTU791ESTIC W= <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS L. <br /> In ustria ;Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 1 <br /> Domestic/public Driven Gauge of Casing <br /> t-- Irrigation Gravel Pack Depth of Groute�, A&:� <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other InformatioT n <br /> Geophysical Surfane Seal Instate ed-by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: [7State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth_ <br /> Describe Material and Pro--ce-8—ure <br /> I hereby certify that I have prepared this application and that the wcrk will be done isi accordant( <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San loz)M n Local <br /> Health District. Home owner or licensed agent's signature certifies the followinu_ : <br /> "I certify that in the performance of the work for which this hermit is issue . i shall <br /> not employ any person in such manner as to become subject to Workman's Compen=stiln <br /> laws of California." <br /> I WILL CALL FOR GROUT IN PECTION PRIOR TO GROUTING ANDA FINA -:INSPECTION. <br /> SIGNED c - TITLE: _ DATE: ' 7 l <br /> D W PL LAN ON REVE SI E <br /> R DEP. MENT US ONLY �.-ism ti001 <br /> PHASE I <br /> PPLICiVrION ACCEPTED BY �� i�fN DA E <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION_ PHASE�)II4 FI L INSP CTION <br /> INSPECTION BY DATE- INSPECTION BYE �1 //c�at� DATE� ��'� <br /> EH 74 26 Rev. 9/78 9/78 2M <br />