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'` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. 16—,44.�iEXACT STREET ADDRESS � 3 CITY/TOWN <br /> Phone J61 <br /> Owner's Name <br /> Address 1 p '�> r Ci ty <br /> Contractor's Name t, License# !,272. Phone_ 3- ?^»r F,, _ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES go <br /> TYPE OF WORK (Check) : NEW WELL 0- DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER(J <br /> PUMP INSTALLATION Q PUMP REPAIR E" PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER- LINES ..._ PIT PRIVY <br /> SEWAGE -DISPOSAL _FIELD CESSPOL/SEEPRBE 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 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 y: _ <br /> PUMP INSTALLATION: Contractor 4L J � -- - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: p 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. Nome 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 y. <br /> not employ any person in such manner as to become subject to Workman's Compensation �1 <br /> laws of California. <br /> I WILL CALL A hROUT I&VECTION PRIDA TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 6 r� <br /> WDRAW PL ON REVERSE SI <br /> R DEP RTMENT USE ONLY <br /> PHASE <br /> ATPLI�ATTON ACCEPTED BY'� DATE <br /> ADDITIONAL COMMENTS: T <br /> PHASE II GROUT INSPECTION -- PHASE III FINAL INSPECTION / <br /> INSPECTION BY DATE INSPECTION BY 4 ./ DATE <br /> EH 14 26 Rev. 9/78 0/ 8 _2 <br />