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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 9- V3)? .— <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued.,�r,3_? <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 /> EXACT STREET ADDR S 0. CITY/TOWN <br /> Owner's Name <br /> Address / Phon <br /> r n <br /> City <br /> Contractor's Name a -,, � <br /> L i c e n s Phone /-;� S�1 <br /> IS CERTIFICATE OF WORK"IAN'S =11PENSATION INSURA?!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN G RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 . WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION � PUMP REPAIR CI PUMP REPLACEMENT 0 `> <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PI OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WEL <br /> INTENDED USE TYPE OF WELLy <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private —Drilled Dia. of Well Casing <br /> ��Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> ____Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of ` <br /> p / H. . <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑Stara Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materldl and Procedure Approximate Depth <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 <br /> WILL CALL R A GROUT INSPECT IOR TO GROUTING AND A FI-NAL INSPECTION. <br />:SI:GNED <br /> TITLE: e` .u� DATE:� �c <br /> DR W PL L N ON REVERSE SIDE —' <br /> PHASE IR DEPARTMENT USE ONLY <br /> APPS ION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I n J OAT E•3=3 <br /> PHASE II GROUT IN <br /> INSPECTION BY SPECTION PHASE III FINAL INSPECTION <br /> DATE <br /> FN 74 26 Rev. 9/78 INSPECTION BY �f_ d4 , DATE - 1 <br /> 9/78 <br />