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I <br /> SAN JOAQUIN LOCAL HEALTH, D•ISTRICT <br /> FFICE 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 1,1-11-,7e <br /> (Complete In 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 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 ADDRESS Cy2P v CITY/TOWN I� <br /> Owner's Name Jt&&,J/ / Phone <br /> Address City <br /> 'Contractor's Name `_License Phone — L_ , <br /> IS CERTIFICATE ,OF WORK�tAPJ'S CO";PENSATIOtd IPJSURA" £ ON FILE WITH SJLHD? YES Z.; No' <br /> TYPE 0_F WORK (Check)': NEW WELLS DEEPEN Q RECONDITION ® DESTRUCTION( <br /> .— WELL CHLORINATION Q WELL ABANDONMENT ® OTHER 0 <br /> PUMP INSTALLATION 05---PUMP REPAIR E7 PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST SEPTIC TANI4QOSEWER LINES Q..PIT PRIVY <br /> SEWAGE DISPOSA FIELD —C SSP L/SEEPA E PIT�Q CHER <br /> PROPERTY LINEA VRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Film <br /> INTENDED USE _ _. TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> .Industrial Cable Tool Dia, of Well Excavation <br /> __Domestic/private gilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C_ <br /> Irrigation Gravel Pack Depth of Grout Sea ¢— <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal- --..- _ ,. ---Other - Other Information <br /> Geophysical Surface Seal .Instar ed b . <br /> PUMP INSTALLATION: Contractor �"1lillf l� <br /> Type of Pump _ H. <br /> PUMP REPLACEMENT:. r]State Work Done <br /> PUMP REPAIR: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter --= - .Approximate,Depth <br /> Describe Material an2 Procedure <br /> I <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 /> . Taws of California. " s <br /> I WILL CALL--EQgA GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. ; <br /> SIGNED _ <br /> _ _� TITLE:' /fDATE: 1. d,: <br /> / <br /> (DRA rLUT PLIAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE „z <br /> ADDITIONAL COMMENTS : <br /> PHASE IT GROUT INSPECTION PHASE III ' FINAL INSPECTION <br /> INSPECTION BY 1 DATE INSPECTION BYINK_ Kkefl. DATE <br /> EH 14 26 Rev. 9/7R . . . o N7 e)M > <br />