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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , 'Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL .CONSTRUCTION OR PUMP PERMIT Date Issued _3-72 <br /> This Permit. Expires 1 Year From Date Issued <br /> Complete In Triplicate). <br /> Application is hereby. -made toithe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This applAcation -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 /> l EXACT STREET ADDRESSCITY/TOWN <br /> Owner's Name Phone�� <br /> Address - City_ <br /> f Contractor's Name License# Phone Z5-1 L <br /> IS CERTIFICATE OF WORKIIAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES lr NO <br />( TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION DESTRUCTION�. <br /> WELL CHLORINATION C3 WELL ABANDONMENT CI OTHER 0 <br /> PUMP INSTALLATIONS PUMP REPAIR❑ PUMP REPLACEMENT [] <br /> { Vf <br />(' DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINES PIT PRIVY <br /> SEWAGE- DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />'F 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 /> , =LDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing , <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysicalii�� 1 Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor _1 F&A <br /> Type of Pump H.H.P. , <br /> a <br /> PUMP REPLACEMENT: ❑State Work Done <br />' PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br />' I hereby certify that I have prepared this application and that the work will be done in accordance <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 TITLE: DATE: <br /> PLT PLAN ON REVERSE DE <br /> FOR DEPARTMENT ISE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : ' <br /> PHASE II GROUT INSPECTION PHASE III -FINAL INSPECTION <br /> d <br />, INSPECTION BY DATE INSPECTION BY DAT -- <br /> :CID 1 A7C ❑.,.. 1-3 77 ,.• dPT' S � - '1 �'753i� 7Nf <br />