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� c � i313 <br /> Gf' SAN JOAQUIN LOCAL HEALTH U1SINIC1 <br /> FFICE USE: 1601 E 'azelton •Ave. , Stockton, CA S 15Permit No. 79-u57 <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued;-/0 -7 9 <br /> This Permit Expires 1 Year From Date Issued <br /> Complete . n Triplicate) <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 cordpliance with San <br />.'oanuin County Ordinance 'gib. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. ' <br /> EXACT STREET ADDRESS CITY/TOWN__\: <br /> Owner' s Name Phone — <br /> Address City <br /> Contractor's N a m A. Licenseb Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIQ ! INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW.WELL[�( DEEPEN O RECONDITION C3DESTRUCTION❑ <br /> WELL CHL RINATION Q WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL ' ,.IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -„ P'RIVATE DOMESTIC. WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 9 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial CaOe Tool Dia. of Well Excavation <br /> c/6omestic/private Drill ed Dia. of Well Casing /< <br /> Domestic/public --Driven - Gauge ,of Casing <br /> Irrigation Graved_ Pack Depth of Grout Sea r <br /> ------------ <br /> Cathodic Protection ' !/Potary Type of Grout _ <br /> Disposal Other.. Other Information J <br /> Geophysical , Surface Seal Installed by: ; <br /> PUMP INSTALLATION: . Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Dobe <br /> PUMP REPAIR: ❑State. Work Done <br />(DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material, and Prooe ure <br /> I hereby certify that I.' have prepared this application and that the work will .be done in accordanc <br /> with San Joaquin County Ordinances, State.Iaws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed:agent's signature certifies the following: <br /> "1 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 TQ;GROUTINGFAND A FINAL INSPECTION. <br /> SIGNED TITLE : DATE: <br /> I W PL L N ON REVERSE SIDE <br /> =` FOR DEPARTMENT USE ONLY <br />,PHASE I - <br /> PP�LIUTION ACCEPTED BV t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT IRSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 1J r J DATE: 77 INSPECTION BY C DgrMM2,jATE�p//Tj-7Lj <br />