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SAN JOAQUIN LOCAL HEALTH DISTRICT s, <br /> FFICE .USE: 1601 E. Hazelton Ave., Stockton, CA 95205 Permit No. 7 <br /> Telephone--7M) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> { <br /> This Permit Ex fres l Year From Date Issued <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 /> -- <br /> EXACT STREET ADDRES <br /> .� �t � ' ' CITY/TOWN <br /> S �' r t t r <br /> Owner's Name ��• t �. l1, < y Phone <br /> Address -I( t��_ ?', City <br /> Contractor' s Name ' .. .� ! ,:: , License#,�7,S',?VPhone Vi "'- <br /> IS CERTIFICATE OF WORKMAN'S C41,1PENSATIOI! INSURA'MCE ON FILE WITH SJLHD? YES X 'i0 <br /> TYPE OF WORK (Check) : NEW WELLEY DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT CJ- OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT q <br /> DISTANCE TO NEAREST: SEPTIC TANK:,'` e SEWER LIPES„ � PIT PRIVY <br /> SEWAGE DISPOSAI FIELD,�- o CESSPOOL/SEEPAGE PIT "" OTHER <br /> = PROPERTY LINE '", .'PRIVATE DOMESTIC WELL='' 4 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing f <br /> Domestic/public Driven Gauge of Casing c /j, Xf r. <br /> Irrigation k Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout .s <br /> Disposal Other Other Informationr�, <br /> Geophysical Surface Seal Instar ed by: 4,, 1,rA <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-d Procedure <br /> t <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 r� d_ '' TITLE: 4 ' r,"..° ATE:. <br /> ---- (DRTW PL T .PL N ON REVERSE:iSIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i t ` <br /> APPLICATION ACCEPTED 8Y ' DATE <br /> ADDITIONAL COMMENTS : ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY DATE ) <br />'Pli 1 Q9F Qac 17_77 ___ _ 1 /78 2M <br />