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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOR 6F6FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _ .3 <br /> *; Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued a �T <br /> (complete In Triplicate) <br /> 7aper!y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct. <br /> and/or instal,l.. the work herein..described. This application is made in compliance with San <br /> Joaquin County Ordinance .No. 1862 and the Rules and' Regdlations of the San Joaquin Local Health <br /> District. � x <br /> �..� <br /> EXACT STREET ADDRESS CITY/TOWN �zSG <br /> Owner's `Name ti Phone <br /> Address 'Z 2 City <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'SICOMPENSATION INSURAINCC' ON FILE WITH-SJLHD? YES No. <br /> TYPE OF WORK (Check) : NEW WALL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ W <br /> WELL 'CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 9a <br /> PUMP INSTALLATION EF PUMP REPAIRM' PUMP REPLACEMENT ❑ 41- <br /> W . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL CESSPOOL/SEEPAGE PIT OTHER �} <br /> PROPERTY LINE - 'PRIVATE Dl�MESTIC WELL PUBLIC D MESTIC W�E�LL <br /> INTENDED- USE " ' TYPE OF.WELL^ CONSTRUCTION SPECIFICATIONS <br /> ' Industrial 4 Cable Tool — Dia. of W-eMExcavation <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 ; <br /> PUMP INSTALLATION: Contractor .0- <br /> 1/KA--Type of Pump _ H.R. <br /> `PUMP REPCACEMENT: []State Work Done <br /> 'PUMP REPAIR: ❑State Work Done <br /> !DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Materia and rocedure �- <br /> .'I hereby certify that I have prepared this application and-that .the' work will be done in -accordand <br /> 'with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaqui;n -Local: <br /> #Health District- Home owner or-licensed-agent's s-ignature 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 ofr California. " <br /> WILL CALL FOR A GROUT INSPECTION PRIOR' TO GROUTING_ANFA FINAL INSPECTION. <br /> 'S'IGNEDTITLE: DATE: <br /> --(DRAW P T PE' N ON REVERSE SID£_ <br /> F R DEP ENT-USE- ONLY <br /> PHASE I <br /> TPPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:: . 7. - r - <br /> PHASE,-1- GROUT INSPECTION PHASE III ' =INAL INSPECTION <br /> INSPECTION BY DATE_ INSPECTION BY DATE --'Z— <br /> EH 14 -26 Rev. 9/78 1 . 9/78 29-1 <br />