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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205Permit No. _ ob <br /> Telephone: , (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued?-45-7.9 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Jo <br /> ' aquin Local Health District for a permit to construct <br /> andtor install the work herein described. This application is made in compliance with San <br /> Joaquin Cou'nty_Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. 4a7��» i <br /> EXACT STREET ADDRESS .S6-1 CITY/TOWN .Qcg/yl +G ' <br /> Owner's Name re Phoneme <br /> Address (o City <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORK'1AN'S COMPEINSATION INSURAINCE ON FILE WITH SJLHD? YES NO ! <br /> TYPE OF WORK (Check) : NEW WELL Cl DEEPEN Ci RECONDITION❑ DESTRUCTION M <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT Ej � <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 re d r <br /> Type of Pump g,Aw. H.P. <br /> .PUMP REPLACEMENT: r] State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> bESTRUCT'.ON 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 accordano <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local. <br /> Health District. Nome 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 NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 1 <br /> DRAW PLOT PLAN ON REVERSE SIDE i <br /> FOR EPA IfMENT U E ONLY <br /> PHASE I q <br /> APDL.CATION ACCEPTED BY DATE 71 <br /> ADDITIONAL COMMENTS : I � <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION -BY-(-ve DATE 1z1�U`7 f <br /> yL11. 14 26 Rev. 9/73 5/79 2M <br />