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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: r 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.79'-16 9,;?, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -,20 7 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete, In Triplicate <br /> Application is hereby made to the San Joaquin' Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with .San 4 <br /> ,'eanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Uistrjct. 3 <br /> EXACT STREET ADDRESS CITY/TOWN r <br /> Owner' s Name Phone LCf <br /> Address <br /> i <br /> Contractor' s Namezx SA <br /> License#twy-,60 Phone i <br /> .. <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"JCE ON FILE WITH SJLHD? YES V--- NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERF-3 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT �] <br /> i <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private v Drilled Dia. of Well Casing (/ <br /> Domestic/public Driven Gauge of Casing LitCr <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H• .- <br />'. PUMP REPLACEMENT: []State Work Done <br /> tPUMP 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 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 ROU INSP CION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />! SIGNED TITLE: DATE: <br />� PLOT PLAN- ON REVERSE SIDr <br /> FOR DEP EN USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DAT, . _ <br />; ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III_ FJNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B i �� DATE f�— '2L <br /> I", „--- ,., ,., .. . 1 /78 2M <br />