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t` SAN JOAQUIN LOLAL HLAL I H uIJ I ILII,i <br /> i FFKCE USE: 1601 E. Hazelton Ave. , Stockton,` CA 95205 Permit No. 'r' / <br /> Telephone: (209) 466-6781 <br />(-- APPLICATION FOR WELL CONSTRUCTION OR' PUMP PERMIT Date issued 3 �� <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Trip icate <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 /> ,;oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health <br /> District. <br /> L <br /> EXACT STREET ADDRESS / CITY/TOWN <br /> Owner's Name _ Phone <br /> a <br /> Address City <br /> Contractor's Name License#, SMI/2 Phone - 3 -- <br /> 'S CERTIFICATE OF WORKMAN'S COIIPENSATION INSURA'fCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL U§ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEI&OPRIVATE DOMESTIC WELL 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 41 <br /> Domestic/public Driven Gauge of Casing <br /> rrigation Gravel Pack Depth of Grout Seal 17n, <br /> Cathodic Protection Rotary . "Type of Grout /1,,, <br /> a <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <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 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 TITLE: DATE: 1-7 It <br /> DR W PLOT PLFN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PP�LICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSP T PH E III FINAL INSPECVION <br /> INSPECTION BY /fs DATE INSPECTION BY DATE . <br />-EH 1426 -- Rev. 12-77 _- _ 1/78 1__2M <br />