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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - o <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _g_2f <br /> (Complete In Triplicate) y <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 Local Health <br /> District. <br /> EXACT STREET ADDRESS 4/ y <br /> �s..�.� CITY/TOWN <br /> Owner's Name Phone I-), D <br /> Address U City ' <br /> Contractor's Name License# Phone,, <br /> IS CERTIFICATE OF WORKMAN'S CO"►PENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> _ - J <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION ❑ DESTRUCTION[n 41 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 .s <br /> PUMP INSTALLATION ❑ PUMP REPAIRO- PUMP REPLACEMENT Q 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALFIELDCESES P6L/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 /> PUMP INSTALLATION: Contractor <br /> Type of Rump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: 933tate Work DoneF AV <br /> _ <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 CALLUR A_GROUJ LNSPECTION P TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE:oZ r <br /> )RAUPLOT PLAN ON REVERS IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APZ- <br /> PLI ATION ACCEPTED BY el � - DATE 2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> z�, <br /> INSPECTION BY �. DATE INSPECTION BY C DATE 3 <br /> EH 14 26 Rev. 9/1$ 9j78 2M <br />