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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued _g-� <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. F <br /> EXACT STREET ADDRESS �o •� �° CITY/TOWN�jI 6r. <br /> Owner's Name " C _...._:._. Phone <br /> Address, / City - <br /> Contractor's Nam V1 a Licens � Phone y <br /> r __ 7 3y_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES O <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION] WELL ABANDONMENT Q OTHERI:3 q. <br /> PUMP INSTALLATION ❑ PUMP REPAIR0- PUMP REPLACEMENT E <br /> DISTANCE TO NEAREST: SEPTIC TANK oc-, SEWER LINE c��eD PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPGO <br /> L/SEEPAGE PIS— OTHER <br /> PROPERTY LINE - PRIVATE DORIESTIC 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_ l <br /> Domestic/public Driven Gauge of Casing <br /> �.-- Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection _ Rotary Type of Grout <br /> LLL2isposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor �z <br /> M Type of Pump <br /> PUMP REPLACEMENT: []State Bork Done <br /> ' PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WEl_L�­ 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 accordant <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. <br /> DR W PL N ON REVERSE SI E <br /> PHASE I R DEPARTMENT USE ONLY <br /> PA�LICATION ACCEPTED BY DATE .,2 •7- 7rJ <br /> ,ADDITIONAL COMMENTS: <br /> PHASE II GROUT _INSPECTION' PHASE III, FINAL INSPECTION <br /> INSPECTION BY DATE .,.. <br /> INSPECTION BY D TE '�- <br /> EH 14 26 Rev. 9/78 9/78 2M <br /> :g <br />