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Corwa"" R SAN JOAQUIN LOCAL- HEALTH DISTRICT _ <br /> I FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-5781 t <br /> 1 • _ S' <br /> APPLICATION FOR WELL CONSTRUCTION 0.R PUMP PERMIT Date Issued <br /> This Permit Expires l Year From Date Issued } <br /> Complete In Triplicate <br /> ; <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 /> .'oacauin County Ordinaa'ice No. 1862< and the RulesandRegulations -of the San Joaquih Local Health i <br /> District. <br />, EXACT STREET ADDRESS <br /> CITY/TOWN <br /> Owner' s Name_. �,� F 1� "� d- or <br /> Phone <br /> Address 4 )K- -- City cc. /�,.. <br />' Contractor's Nam utam <br /> 7 <br /> License# hone �66,a '26 �- __ <br /> IS CERTIFICATE OF WORKHAi1'S C PENSATION INSURANCE O'N FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION p WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ -� <br />, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -- <br /> INTENDED- USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> s. 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 c.4 <br /> Type of Pump H.P.04* <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP fteftla_ E]State Work Done r� <br /> �DESTRUCT'rON�OF-WELL--'-Well D-iameter 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 accordanc( <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 /> f "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 dl <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSP TIGN P TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED u/ _/ ITLE: - DATE: <br /> DR . PLOT PL ON REVERSE SIDE <br /> FOR DEPA TME T USE ONLY <br /> ' PHASE I - <br /> iAPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION r <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> rU ,AOC . n :. 1`3 -77 i1-/-7-8 .. 2M <br />