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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR -OFFICE USE: 1.601 E. Hazelton A..", Stockton, CA 95205 Permit No. <br /> D <br /> Telephone: 2 ) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued ✓a3 j <br /> (,Complete In Triplicate) <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 /> Joaquin County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET. ADDRESS CITY/TOWN <br /> Owner's Name�A41w� _ 60 Phone <br /> f- g <br /> Address � _ __ City. ^� � : <br /> Contractor's Name License#i ZJif/ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION 'INSURANr. ON FILE WITH-SJLHD? YES Ror � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITIONJ2 DESTRUCTION d � C <br /> WELL.`CHLORINATION C3 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION L7 PUMP. REPAIR 0-- -PUMP REPLACEMENT Q JQ <br /> DISTANCE TO NEAREST: SEPTIC TANK50_ SEWER L`1NES - PIT PRIVY -- <br /> SEWAGE DISPOS�L FIELD CESSPOOL/SEEPAGE PIS-c- OTHER -- <br /> PROPERTY LINE PRIVA E DO ESTIC WELLfPUBLIC DOMESTIC WELD--- <br /> INTENDED USE' TYPE OF -WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of-well Excavation Ig <br /> —� Domestic/private ;a Drilled Dia,. of Well Casin <br /> Domestic/public R = 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 of Pump H.P. <br /> `PUMP REPLACEMENT: F]State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF' WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <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 /> 1 WILL CALL FORA G KUT. I SPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:,;?a _ <br /> DR W PL T PETN ON REVERSE SIDE <br /> FOE DEPARTMENT/qJSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY4 DATECZ . / <br /> �3 7 <br /> ADDITIONAL •COMMENTS: <br /> PHASE II. GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY4L�\G-%toDATE Lp I2 NSPECTION BY DATE <br /> 4 <br /> 1EH 14 26 Rev. 9/78 Q� g.� _ .. o�c w 9/78 2M <br />