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SAN JOAQUIN LOCAL HEALTH UISI K10 <br /> OFFICE USE: 1601 E. Hazelton.:Ave. , Stockton, CA 95205 Permit No. 7 _ a- <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /:3.,y <br /> This Permit Ex ires 1 -Year from Date Issued <br /> Complete In Trip -icate <br /> { Applicati.on is hereby madelto 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 /> Joaquin County Ordinance No., 1862 and the Rules and Regulations of the San; Joaquin Local Health <br /> s District. I rr <br /> EXACT STREET ADDRESS _ `4 � ,I G-r-d :JA _1r.� CITY/TOWN 6�, r <br /> w .Owner's Name _ ._ -_ /V Phone . <br /> Address �,.�6,� -7 ` City �� <br /> — - <br /> Contractor' s Name = , Li cense# �Phone q6-4. <br /> IS CERTIFICATE OF WORKMAN S COMPEN TIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN [] RECONDITION ® DESTRUCTION <br /> WELL CHLORINATION j] WELL ABANDONMENT 0 OTHER 0 Q <br /> PUMP INSTALLATION Da PUMP REPAIR 0 PUMP REPLACEMENT Q .ice <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 Sea <br /> Cathodic .Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type ;vf Pump H.P. -4-Z) <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP Rte: (&State Work Done ...w,,� <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 accordanc <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 --c`ertify 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. " f <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND A FINAL INSPECTION. <br /> SIGNS j ITLE: r DATE: / <br /> (DRAW PLOT PL ON REVERSE .SIDE <br /> FOR DEPA TMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION., PHASE III FINAL INSPE TION <br /> INSPECTION BY DATE <br /> INSPECTION BY .ate,_— DATE <br /> ,EH 1426 -.Rev- 12-77 1 /78 2M <br />