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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =0R• OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7-1�-�q <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Wor install the work herein described. This application is made in compliance with San <br /> aquin County Ordina ce No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> strict. p <br /> ACT STREET ADDR ' CITY/TOWN r� <br /> ner's Name Phone <br /> 1 <br /> dress City: _> S � / <br /> ntractor's Name - Licensed _ Phone <br /> CERTIFICATE OF WORKi,AN'S C0,11PENSATIOIN INSURANCE ON FILE WITH SJLHD? YES NO <br /> 1E OF WORK (Check) : NEW WELL.P DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> STANCE 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 Sea <br /> Cathodic Protection =Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> 1P INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �P REPLACEMENT: ❑ State Work Done <br /> '1P REPAIR: ❑State Work Done <br /> STRUCTION OF WELL: Well Diameter 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 /> th San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> 31th 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 /> ,JILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ]NED — TITLE: DATE f' <br /> DR W PLOT PL N ON REVERSE SIDE <br /> ASE I <br /> FOR DEP RTMENT USE ONLY <br /> ?LICATION ACCEPTED BY DATE <br /> DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> �PECTION BY DATE INSPECTION BY DATE <br /> 14 26 Rev. 9/78 9/78 2M <br />