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SAN JOAQUIN:-LOCAL- HEALTH DISTRICT <br /> JOR <br /> OFFICE USE: 1601 E. Hazelton Ave:.;° Stoc�kton;"GA. 52O5 Permit No.Z �a __ <br /> Telephone: , (209) 466-6.781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3� 3 <br /> This.,Fermi t,,Ex i res .,1,.Year ,From,Zate;:Is,sued.. ; <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin` Local-Health- District for a permit to .construct ' <br /> and/&- install the`wo'ek herein described. This .application is made in compliance with San <br /> Joaquin County'`Grd i Hance '"1.4'o., 1862 and the Rules and, Regu.l at ons of the San- Joaqui n, Local Health <br /> Clistr�ct. ' <br /> p � . f['6 <br /> EXACT STREET.ADD S. CITY/TO1N <br /> Owner' s Name Phone <br /> Address . <br /> Contractor's NamLicens <br /> e e#, -37-3 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES L i NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION� �� �,. <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER �- <br /> PUMP INSTALLATION CI PUMP REPAIR O PUMP REPLACE NT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C►� <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 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 /> IPUMP REPLACEMENT: ....�]Sttate Work Done <br /> PUMP REPAIR: 21ltiate Work Do f <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 accordandi <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: 3.9- ' <br /> DR W PLOT PLAN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / DATE <br /> APPLICATION ACCEPTED BY < '4z", -Y4:!,�- <br /> ADDITIONAL COMMENTS: / If :::�3 <br /> I PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a-7 <br />