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SAN JOAQUIN LOCAL HEALTH DISTRICT y "" <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit. No.--76—CI-7 3 <br /> Telephone: (209) 466-67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued(, I �7_ <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 /> 2oanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distract. <br /> EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name Phone <br /> Address City <br /> Contractor' s Name -�� �� �<,� ,�,c�_ <br /> License#3_�,y'q�2/ Phan.e �— G <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTION[] <br /> WELL CHLORINATION p WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION IR PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY U, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <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 Seal <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 Pump H.P. ! <br /> PUMP REPLACEMENT: ❑ 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 CA OR A GR UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION: <br /> SIGNS TITLE: DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE e�; <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSP CTION PHASE III FIML INSPECTI <br /> INSPEIrTION BY DATE I PECTION BY DATE -7 <br />`EH. 1426 Rev. 12-77 1/78 2M_` <br />