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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (� 209) 456-678I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> (Complete In Triplicate) <br /> �� <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 /> 5 <br /> EXACT STREET ADDRESS /S3 CITY/TOWN <br /> Owner's Name Zr ,r A41 r- Phone- ;'Z,2 2, 6 <br /> Address s City <br /> Contractor's Name �� License# Phone /6 <br /> IS CERTIFICATE OF WORKMAN'S CO"�PENSATION INSURA'ICE- N FILE WITH SJLHD? YES NO— <br /> TYPE OF WORK (Check) : NEW WELL W DEEPEN ❑ RECONDITION ❑ DESTRUCTION[ 1, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ W <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q v <br /> DISTANCE TO NEAREST: SEPTIC TANK /ao6'�SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSALS FIELD / CESS066 /SEEPI GE PIT - OTTER -- ` <br /> PROPERTY LINX4PRIVATE DO 'IESTIC WELL/96 4- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of We 1 Excavation go <br /> Domestic/private Drilled Dia. of Well Casing ,P <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 b Q <br /> PUMP INSTALLATION: Contractor 7� . <br /> Type of Pump— �� .�Jja'j _ _ H.P.�7 — <br /> PUMP REPLACEMENT: State Work Donee ` <br /> PUMP REPAIR: ❑State Work Done d4' sn P <br /> DESTRUCTION OF WELL.: Well Diameter Approximate Depth <br /> Describe Material and Procedure - -- <br /> 1 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 QROUWINKTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE: _ DATE: <br /> a .(DRAW PLOT PLAY ON REVERSES £ <br /> OR DEP RTMEN SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I PHASE III fINAL INSP CTION <br /> INSPECTION BY DATE / INSPECTION BY DATE <br /> EH 14 26 Rev--9V78 039/78 2M <br />