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SAN JOAQUIN LOCAL `HEALTH DISTRICT ' <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 179- <br /> Telephonq., J49) 466-6781 <br /> APPLICATION FOR WELL"CONSTRUCTION OR PUMP PERMIT Date Issued r 3 <br /> T61is Permit Expires 1 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 th R 1' and Reg lations of the San Joaquin Local Health <br /> District. ���7 � / • <br /> EXACT STREET ADDRESS 2ITY/� <br /> %T 0 W N ' <br />` Owner' s Name Phone <br /> Address <br /> c,ty /� <br /> Contractor's Name Licenset,2W& Phone_�'f1 ,'r" <br /> IS CERTIFICATE OF WORKMAN'S 0OMPENSATiO"1 I�AIIRAFECE OFl FILE WITH SJLHID? YES NO <br />( TYPE OF WORK (Check) : NEW WELL 0 DEEPEN El 'V ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION M POMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIWY <br /> r <br /> SEWAGEJ DISPOSAL FIELD_10 <br /> 42 CESSPOOL/SEEPAGE PIT OTHER <br /> I PROPERTY LINE -, PRIVAT DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTROCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ---)C`Domest,c/private Drilled Dia. of Well Casing '� <br /> Domestic/publicDriven - Gauge of Casing ,, <br /> Irrigation -X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _x Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: % Contractor " <br /> ' Type of Pump <br /> H.P. <br /> I <br /> PUMP REPLACEMENT:—'AJ- ❑State Work Done " F <br /> PUMP REPAIR: . ❑State Work Done? F <br /> DESTRUCTION OF WELL: Well Diameter l Approximate Depth <br /> Describe' -Mater,a T'an 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 Regulat,ions ,of the San Joaquin Local ; <br /> Health District. Home owner or licensed agent-'s--signature certifies ,,the_fol.lowing: ` _ i <br /> "I certify that in the performance -of the-work .for._which_this permi.it-is _issued, I shat1 <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 SPECTION PRIOR GROUTING AND A F AL INSPECTION. <br /> SIGNED TITLE: DATE: q <br /> OT PLWON REVERSE IDE <br /> i <br /> t FOR. DEPA TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY sir !�Xf DATE <br /> ADDITIONAL COMMENTS : <br /> PHA5E II GROUT I ,SPEGTION PHASE I I FINAL INSPECTION . ' <br /> INSPECTION BY DATE - -? INSPECTION BY DATE -19- <br /> I <br /> r <br /> EH 7.426" Rav_ 19-77 J75/4- <br /> ,. �' • � �, <br />