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t � _I9SAN *-JOAQUTN LOCAL HEALTH DISTRICT <br /> FFICE USE:rs.ry - 1601 E. HazeltorL.Ave,- Stockton, CA 95205 Permit No.79- 1�6. _ <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -1p _? <br /> This Permit. Ex ices 1 Year From Date"Issued <br /> Complete In Triplicate-) ' <br /> Application is hereby made to the San Joaquin Local Health Distr.ict. for. a permit to con,st.ruct <br /> and/or install the work- herein described. This application is made in compliance with San . <br /> ,'oanuin County Ordinance 14o. 1862 and the Rules and Regulations of the San. Joaqun Local Health <br /> District. <br /> EXACT STREET ADDRESS /S CITY/TOWN <br /> Owner' s Name Phone <br /> Address City <br /> Contractor' s Name License Phoner�oZ— <br /> IS CERTIFICATE OF .WORK"IAN'S OSIPENSATION INSURA"ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I ustrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled. Dia. of Well Casing .s <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation,,- Gr vel Pack Depth of, Grout Seal <br /> Cathodic Protection otary Type of Grout <br /> Disposal Other Other Information <br /> Geophysica1 _. Surface Seal Installe by: - <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: QState Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYa_ '� <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 1 D TE -, �_ INSPECTION BY <br /> th I <br /> 7m��_ . <br /> /� .�{ <br /> ATE g <br />