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S JOAQUIN LOCAL HEALTH DISTRICT <br /> OR FFICE USE: 1601 E`Iazelton Ave. , Stockton, CA 95� Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedy- 3-7 <br /> This Permit Ex fres 1 Year From Date Issued <br /> Complete In Triplicate <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> /or install the work herein described. This application is made in compliance with San <br /> ,Quin County Ordinance 1+o. 1862 an the Rules and Regulations of the San Joaquin Local Health <br /> str^ct. <br /> nCT STREET ADDRESS /,;A�f CITY/TOWN <br /> .er' s Name 'Qo4ciJzS Phone_ �I <br /> dress City aLr. <br /> ntractor's Name J-7-/9 License;9, Phon 1 <br /> CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES °� NO <br /> PE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ �i <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 Cr <br /> PUMP INSTALLATION Mr PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <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 by: <br /> MP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> MP REPLACEMENT: ❑State Work Done <br /> ;MP REPAIR: [Mate Work Don <br /> :STRUCTION OF WELL: Well Diameter tl Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordant <br /> Ith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> alth 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 /> WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iGNED {2 /✓XR TITLE: DATE: ,?.9-- 79 <br /> DRAW PLOT PL N ON REVERSE SIDE)_ <br /> FOR D P RTMENT US ONLY <br /> iASE I <br /> 3PLICATION ACCEPTED BY DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> JSPECTION BY DATE INSPECTION BY DATE �- <br />