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A.•- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave.,, Stockton, CA 95205. Permit Vo, <br /> Telephone: {cD9) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 6 17 <br /> This Permit Expires 1 Year From Date Issued <br /> Lti 7' 7 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 inIcompliance with San <br /> ,'oaQuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. dF <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone <br /> NJ <br /> Address City <br /> Contractor's, Name License# & Phone Y �2_ D 3 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATI ka INSURANCE ON FILE WITH SJLHD? YESNO <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN ❑ RECONDITION ❑ DESTRUCTION[2 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ O <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 §PECIFIOJIOS <br /> Ind trial Cable Tool ' Dia. of Well Excavation. <br /> gestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack ' Depth of Grout Seal SO/ 0C <br /> Cathodic Protection y Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed <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 T 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 certifies the following: <br /> I certify that in the performance of the war or w this permit is issued, I shall <br /> not employ any person in such manner as to b came subjec to Workman's Compensation <br /> laws of California. " <br /> I WILL CALL F0. GROUT INSPECT N RIOR TO GROUTI ND A. FI AL i SPE ION. 7 <br /> SIGNED TIT DATE: <br /> RRW PLOT PL N 0 EVE SIDE <br /> PHASE I i <br /> FOR DEPARTMSrUSE ONLY <br /> APPLICATION ACCEPTED BY DATE `���'' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEtTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE l l� <br /> SEH- 1426 Rev--12--77 - - - -- - 778- 2M_ <br />