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w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR -OFFICE USE: 1601 E. Hazelton Ave. Stockton, CA 95205 Permit No. 1 -616 <br /> Telephone: (209) 466-6781 � 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued l3 7�l <br /> (tomplete , 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 Local 'Health <br /> District. <br /> EXACT STREET ADDRESS -3,33 CITY/TOWN <br /> R <br /> Owner's. Name . Phone 21 _213 <br /> Address 3City_ __ �-— <br /> Contractor's Name License#//Z ,, Phone VS/ <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATION INSURANCE ON FILE WITH-SJLHD? YES �� 0- <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION rl <br /> WELL CHLORINATION d WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION Q PUMP REPAIR 0'- PUMP REPLACEMENT W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ._, u <br /> INTENDED USE TYPE OF-.WELL.. CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia. 'o' f Well Excavation l <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 Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: _ QState Work Done <br /> 4D'ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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: zIP <br /> D W PLOT -PLAN ON REVERSE S <br /> PHASE I FOR DEPARTMENT USE ONLY xv , / <br /> PP�ATION ACCEPTED BY DATE d?/3 <br />(`ADDITIONAL COMMENTS: /7 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />'INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/78 o17Q h <br />