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SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> FFICE USE: � "' <br /> 1601 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) Ph,At sto 40 Iev <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> EXACT STREET ADDRESSQ CITY/ � <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License Phone 79?/ey <br /> IS CERTIFICATE OF WORKMAN'S COP"PENSATION INSb<ANCE ON FILE WITH SJLHD? YES �� N0 <br /> TYPE OF WORK (Check) NEW WELL M DEEPEN Q RECONDITION [l DESTRUCTION a.. <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR E] PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK /�Q SEWER LINES SPIT PRIVY �---- <br /> SEWAGE DISPOSAL FIELD �_ CESSP L/SEEPAGE PIT ,"o THER <br /> PROPERTY LIN9� IVATE DOMESTIC WELL-45-- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of 0 1 Excavatian__ea t <br /> Domestic/private A-17ri11ed Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing C ,� <br /> Irrigation Gravel Pack Depth of Grout Sea { <br /> Cathodic Protection �tary Type of Grout �— <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP IN TALLAT 7ONN: Contractor <br /> Type of Pump H.P.- <br /> PUMP <br /> . .PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce e <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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: �' <br /> PLT LTff ON REVER8E SIDE <br /> PHASE I OR D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY01,-�AZ7, P DATE / 7 <br /> ADDITIONAL COMMENTS: I/ <br /> PHASE II GROUT INSPEC ON PHAW I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B -� /"Z Z <br /> EH 14 26 Rev., 9/78 DATE <br /> 9/78 2M <br />