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SA JOAQUIN LOCAL HEALTH UISIR10 ; <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No, `1q-4l57 <br /> Telephone: ` (20N 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 5-t6 <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 /> U'oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health � <br /> Distr=ct. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's NamePhone <br /> Address City <br /> Contractor' s Name License d Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES &----'NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN [1 RECONDITION C] DESTRUCTION d <br /> WELL CHLbRINATION C] WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION [I PUMP REPAIR❑ PUMP REPLACEMENT [] ' <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 /> &--'6omestic/private Drilled Dia. of Well Casing / s <br /> Domestic/public Driven Gauge of Casing 1-4 <br /> Irrigation Gravel Pack Depth of Grout Sea] r <br /> Cathodic Protection otary Type of Grout f4 ' <br /> Disposal Other Other Information r <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: C]State Work Done <br /> PUMP REPAIR: ❑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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> goor (DRAW PLOT PLAN ON 'REVE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � ��' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IRSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE� 7� INSPECTION BY ATE a <br /> EH 1426 Rev. 12-77 178 .2M <br />