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SAN JOAQUIN LOCAL HEALIM Ui51KIU1 <br /> EOR40E-FftE USE: 1601 E. Hazelton Ave. , 'Stackton, CA 95205 Permit No. Z <br /> Telephone: '` (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> This Permit Ex ices 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 /> .Joaquin County Ordinance No. 1862. and the Rules. and,.Regulations of. the .San Joaquin LocalHealth <br /> District. <br /> EXACT STREET ADDRESS �-p CITY/TOWN <br /> Owner' s Name - -��r��� T Phone - <br /> Address ;-o 4 2_0- City, C <br /> Contractor's Name /, License Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAN ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN W RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER F-J <br /> � . PUMP INSTALLATION M PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO .NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <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 s. Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical , ..- Surface Seal Installed by <br /> PUMP INSTALLATION: Contractor '' <br /> Type of Pump H. . <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR:-- Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia a-na 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. Regulation.s of-the San Joaquin -Local <br /> Health District. Home owner or licensed agen.t.'s. signature :.cert_ifies the following: <br /> "I certify that in th'e 'performance of the work-for which thi s permi tYi s i ss`ued',I-shat l <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 /> (DRAW PLOT PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> TON ACCEPTED BY (,� DATE 4/'S - 7P <br /> COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT'0 <br /> DATE INSPECTION BY�. DATE ') W <br /> ti Rev. 1247 . 7- : . 1/78 <br />