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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 11 Permit. No-7q <br /> Telephone: .,\.(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued y is -2 y. <br /> i� <br /> (Complete In Triplicate), <br /> Application is hereby made to the San Joaquin Local Health District fo:r 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 /> District. <br /> i <br /> EXACT STREET ADDRESS <br /> CITY/TOWN t <br /> Owner's Name 07VI Phone <br /> Address_f� ��. �• ii Ci ty <br /> Contractor's Name License# Phone 6 <br /> IS CERTI-FICATE _OF 14OR-KiiAf4'S-COF'PENSAT.IOfI _INSUf2A4CE`ON 'FILE'WITH.SJLHD? YE5 <br /> TYPE OF-WORK (Check) : } NEW WELL L 4 DEEPEN ❑ RECONDITION Q DESTRUCTION[] <br /> ' WELL CHLORINATION D WELL ABANDONMENT 0 Olj..HER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIRCR- PUMP, REPLACEMENT <br /> DISTANCE TO NEAREST: SEPT;IC ;TAN1C�a�� SEWER LINES � PIT PRI;VIf <br /> SEWAGt .DISPOSAL-FIELD CESSPOOL[SEEPAGE PIiT; ` OTHER <br /> " - PROPERTY LINE 'PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELD <br /> INTENDED USE' TYPE OF-WELL .. CONSTRUCTION SPECIFICATIONS ' <br /> In uust al Cable Tool Dia. of Well Excavation } <br /> Domes tic/priva.te Drilled Dia, of Well Casijng <br /> Domes tic/publ,IC� Driven Gauge of Casing <br /> +---Irrigation ; ) ` Gravel Pack Depth of Grout S6,a. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information' <br /> Geophysical a # Surface Seal Instilled by: <br /> PUMP INSTALLATION: iContrac'tor <br /> Tyoe of Pump b <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: []State Work Don ",v <br /> DESTRUCTION OF WELL: „Weld Diameter Approximate Depth r. . <br /> M'Dd� ribe Material and Procedure <br /> 4 <br /> I hereby certify that I� lia,ve prepared this application and that the -wo.;rk will be done i W..4c'cordanc1 <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local, <br /> Health District. Home-owneror..1.i censed. agent-'-s s i.gnature certifies t;he 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 Californi;a.” <br />.. <br />, I. WILL CALL FOR A GROUT�. INSPECTION PRIOR TO GROUTIN,G(AND• -FINAL-•-INSPE,CTION.—. <br />} SIGNED u <br /> :TITLE: .. <br /> DATE: <br /> iD L L N ON RE SE SIDE <br /> PHASE I t *`' �{ FORIDEP RTMENT USE ONLY <br /> APPLI ATION ACCEPTED BY �T 6I� DATE SZ 6 -=/ <br />,ADDITIONAL COMMENTS: f <br /> PHASE IIiGROUT INSPECTION PHASE ZI 'FI AL INSPECTION '. <br /> INSPECTION BY I " DATE INSPECTION BY DATE <br /> IEH 14 26 Rev, 9/78 9L78 2M <br />