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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE; 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> a Telephone: (209) 466-6781 <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> r.: <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 her6in described. This application is made in compl-iance with San <br /> Joaquin County .Ordinance No! 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS/SW2/m Z7 <br /> Ad., ^_ <br /> Owner's NamePhone��� <br /> AddressLo . r'I— .;� w <br /> C i ty <br />' Contractor's Nameaw License Phon2 11-4z <br /> -IS CERTIFICATE OF WORKMAN'S �COtTI EHSATION INSURANCE ON FILE WITH SJLHD? YESX NO <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN O RECONDITION DESTRUCTION[J <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER Q � <br /> PUMP #INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT [� <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TANKQD SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE RIVATE D MESTIC WELL PUBLIC DORESTIC WELL <br /> INTENDED USE TYPE OF -WELL... r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. .of Well Excavation <br /> Domestic/private ,Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q / <br /> Irrigation ,Gravel Pack Depth of Grout .Sea <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ' <br /> Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br />, `PUMP REPAIR: O State Work Done <br /> 'DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br />' I hereby certify that I have prepared this application and that the work will be done in accordanc <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 isuch manner as to become subject to Workman's Compensation <br /> laws ,of California," <br /> WILL CALL FOR A GROUT NSPECTION PRIOR 'TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED j <br /> TITLE: DATE <br /> t DR W PL T PLAN ON REVERSE SIDE <br /> R DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED-BY DATE <br />',ADDITIONAL COMMENTS: <br /> 2PHAS IT GROUT INSPECTION PHASE IIT FTNAL INSPECTION <br /> IiSPECTION BY DATE �� 48PECTION. BY -OA—� 5 -' <br /> EF! 14 26.�Rev; 9/78 ' 6 9/782M <br />