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SAN JOAQUIN .LOCAL .HEALTH DISTRICT Ll <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209).466-6781 <br /> 'U APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Tri'plicate) cj(00 7 - 3 z -3 z <br /> Application is hereby made to 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 /> ,oaquin County Ordinance No. 1862 �and the Rules and Regulations of the .San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS /f.' r CITY/ <br /> Owner's Name <br /> PhoneC <br /> ITY/TOW <br /> Address ' ' 1 7 City <br /> Contractor's NamLicense P h o n ! <br /> TS CERTIFICATE OF WORKMAN'S COIiP£NSATIOIN INSURANCE ON FILE WITH SJLHD? YES 1:::fNO <br /> TYPE OF WORK (Check) : NEW WELL N DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ ' <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [ � � <br /> • w <br /> DISTANCE TO NEAREST: SEPTIC TANKJLe&o6SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPGOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 4� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS L. <br /> Industrial Cable Tool Dia. of Well Excavation 11 <br /> L,-'Obomestic/private Drilled Dia. of Well Casing ' ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodi-c Protection =Rotary Type of Grout _ ,p ,5 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: L- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and--that the work will be done in accordant( <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 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 /> SIGNED i7 TITLE: DATE: z6g C� <br /> (DRAWPLT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY_1�14 . DATE 6 , ,2..-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - -� INSPECTION BY /D TE ­/1 <br /> EH 1426 Rev. 12-77 1/78 2M <br />