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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 <br /> This Permit Expires 1 Year From Date Issued'` <br /> fl 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 Local Health <br /> District. 1 <br /> EXACT STREET ADDRESS Q042CITY/TOWN' <br /> Owner's Name ' Phone me_ .3g I. <br /> Address Ci ty , � 9 ` <br /> Contractor's Name Licensee Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO M <br /> TYPE OF WORK (Check) : NEW WELL Ci DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER 0 r-/ ��eZl= <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT 11 <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 /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal t Other Other Information <br /> Geophysical .t Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of <br /> Pump H.P. <br /> PUMP REPLACEMENT: 52State Work Done,SAR�;�-� <br /> PUMP REPAIR: ❑State Work Done <br /> r <br /> DESTRUCTION OF WELL: Well Diameter , r Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 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 issu 4shall <br /> not employ any person in such manner as to become subject to Workman's Comp ation <br /> laws of California. " <br /> I WILL CALL FOR A .GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE:, DATE: <br /> DR W PLT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION f <br /> INSPECTION BY DATE INSPECTION BY ATE ..i <br /> rll I AA1C - M-._'"-In -77 - - - � � 1 /78 2M <br />