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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> ! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /� 7� <br /> This Permit Expires- 1 Year From Date' Issued Ir/l/0 All A"O- f =} <br /> Complete n Triplicate _ o&.o w 4 c_ 1.- 7- <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 /> 2-(55 — Z3o—off <br /> EXACT STREET ADDRESS CITY/TOWNS <br /> Owner's Name Phone <br /> Address City 5 <br /> Contractor's Name License Phone <br /> . .?y2-.2,9 is <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO1111 INSURA"JCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL* DEEPEN [] RECONDITION ❑ DESTRUCTION[) <br /> WELL�CHLO INATION Q WELL ABANDONMENT 0 OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT C] - - <br /> DISTANCE TO NEAREST: SEPTIC TANK So r+ SEWER LINES,_ PIT PRIVY -- I <br /> SEWAGE DISPOS4t, FIELD --- CESSPOOL/SEEPAGE PIT OTHER <br /> 6 <br /> y PROPERTY LINE tPRIVATE DOMESTIC WELL-,t PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable. Tool Dia. of Well Excavation Z31 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information lffAz All <br /> Geophysical t . Surface Seal Installed by: 4f'I Alr Al <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <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 I <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 CAL FOR AGROUT IN E IO P OR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: 'nr DATE: O <br /> D W PLIT PLTN_ ON REVE S`E SIDE <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP�PLICATION ACCEPTED BY �( DATEJy,9?�? <br /> ADDITIONAL COMMENTS : LIZ <br /> PHASE II GROUT INSPECTION PHASE III flNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY tet! DATES-—/-7P <br /> EH 1426 RPV_ 19_77 <br />