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(� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Zg�6 yp <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I Date Issued 1,2 <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 for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> -'oaqui n County Ordinance 1co. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Dpi str�ct. <br /> EXACT STREET ADDRESS ` CITY/TOWN • - UIC <br /> Owner' s Name <' Phone `z_KS <br /> Address— W City <br /> Contractor's Name _ Li cense# 76c)o .,,Phone `Z, <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'1 INSURANCE ON FILE WITH SJLHD? YES Y'-' NO <br /> TYPE OF WORK (Check) : NEW WELL$J DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT ❑ OTHER ❑ N <br /> PUMP INSTALLATION,& PUMP REPAIR❑ PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <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 /> Domestic/private C Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout L� <br /> -Disposal Other Other Information <br /> Geophysical urface Seal Installed by: <br /> PUMP INSTALLATION: Contractori4. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: i <br /> O 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 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 G OUT INSPECTION PRIOR TO GROUTING AND A FINAL INS ECTION. <br /> SIGNED TITLE: DATE: s <br /> DR W PLOT PLAN ON REV RSE ID <br /> FOR DEPARTME=NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FJ-NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> c <br /> EH 1426___ Rev. 12-77 1-o-1 I I - - 1 /7� 2M <br />