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OPM <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> MFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit=I -Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITDate I <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. <br /> EXACT -STREET ADDR S o2 Q <br /> CITY/TOWN zoG <br /> Owner's Name •�L'I.,L ' <br /> Phone /3,0F_ <br /> Address / �j City <br /> Contractors Name License# Phone <br /> IS CERTIFICATE -OF WORK"FAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES <br /> NO <br /> :TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION0 <br /> WELL CHLORINATION 0 WELL ABANDONMENT E3 OTHER 0 N <br /> PUMP INSTALLATION �i2 - PUMP REPAIR❑ .. - PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY / <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER , ., <br /> PROPERTY LINE - PRIVATE DO ESTIC WELL PUBLIC GESTIC 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 Informa TE r, <br /> Geophysical Surface Seal Installed �~ <br /> PUMP INSTALLATION: Contractor, t <br /> Type of Pump oz H. . <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State �Wdrk Done <br /> DESTRUCTION OF WELL: Well Diameter t� �` tr <br /> Describe Materia and Proce ure Approximate Depth <br /> I hereby certify that I .have prepared this application+and that the work will be done in accordance <br /> wsith 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: I' <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 Wor�ki� 'n''s Compensation,` <br /> laws of California. " <br /> I WILL,CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE: DATE: <br /> DR PLT L N ON REVERSE SIDE <br /> PHASE I R DEPARTMENT USE ONLY <br /> PP��LICATION ACCEPTED BY Z�/ <br /> ADDITIONAL COMMENTS: DATE d. <br /> PHASE II GROUT INSPECTION y a PHASE 11FINAL INSPECTION <br /> INSPECTION BY DATE . �� INSPECTION BY <br />=H 14 26 Rev. 9/78E 0 <br /> . <br />