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SAN JOAQUIN HEALTH <br /> FFICE USE: 1601 E. Hazelton Avve. , Stockton, CAIC95205 - Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT , Date Issued /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. LL <br /> EXACT STREET ADDRESS CITY/TOWNGI�`]" iv <br /> Owner's NameIf zzPhone ( <br /> Address � , � City <br /> Contractor's Name <br /> License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL S DEEPEN ❑ RECONDITION ❑ DESTRUCTION CI <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR C7- PUMP REPLACEMENT EJ <br /> V <br /> DISTANCE TO NEAREST: SEPTIC TANKS ` SEWER LINES 46 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ICESSp OL/SEEPAGE PI OTHER <br /> PROPERTY LINE/' PRIVA ,. D MESTIC WELL-7-0— PUBLIC DOMESTIC WELD <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool Dia. of We11 Excavation `Z- <br /> Domestic/private Drilled Dia. of Well Casing ,► <br /> Domestic/public Driven Gauge of Casing U <br /> —Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection L-Rotary A Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> .Type of Pump.__ H.P. <br /> PUMP REPLACEMENT: f <br /> ❑State Work-Done <br /> PUMP REPAIR: QState 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 agentls'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. " n <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING'AND FINAL INSPECTION. <br /> SIGNED � TITLE•. DATE: <br /> D W PL _T L N ON RE SE SIDE <br /> PHASE I R " EP MENT U E ONLY <br /> APPS ION ACCEPTED BY -aDATE <br /> 4DDITIONAL COMMENTS: J" Z� /7 <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE L___ -1A-.-1INSPECTION BY DATE - Is 7 <br />-H ]4 26 Rev. 78 8 2M <br />