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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFFOFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Perm.it No.77%--10 a a- <br /> 3 Telephone: - (-209-1 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7-6-7f <br /> !/re/by <br /> .This Permit Ex ires I Year. From Date Issued <br /> (Complete In Triplicate; Application is 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 /> ,oac:uin County Ordinance No J862 'and the Rules and Regulations of the San Joaquin 'Local Health <br />' <br /> District. i `s �}� <br />: EXACT STREET ADDRESS CITY/TOWf�- <br />, Owner's Name "' Phone ' <br /> Address City <br /> Contractor' s Name License r Phone 2-4 3 <br /> IS CERTIFICATE OF WO KMAN"S-7 COMPENSA IO"1 INSURAMCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check): NEW W.ELA� DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ 0 <br /> WELL-CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br />€ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TI <br />' Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done ,_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 <br /> Health District Home owner or licensed -agent' s signature s the following: <br /> "I certify that in the performance of the work for ich this pe mit is issued, I shall <br /> not employ any person in such manner as to becom subject to Wo kman' s Compensation <br /> laws of California." <br /> I WILL CALL F A GROUT INSPE ION PRIOR TO GROUTING A TINA I PE TIO <br /> SIGNEDTITLE: DATE: <br /> DRAW PLOT PL N ON VEVESIDE) <br /> FOR DEPARTME SE ONLY <br /> PHASE I I"k <br /> APPLICATION,ACCEPTED BYDATE -- �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSP TION PHAS6 III FINAL INSPECTIQN <br /> INSPECTION BY DAT INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 >_-,-_ C l7$ 2M <br />