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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j _F _ <br /> OROFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> t Telephone: (209) 466-6781 pate Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> II and/or install the work herein described. This application is made in compliance with <br /> San <br /> l Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District.. yy,, <br /> EXACT STREET ADDRESS 57 4 CITY/TOWN Sdtf� <br /> Owner's Nam `t Phone_ -- <br /> Add ress (� <br /> C i ty <br /> ' Contractor' s Name �� License# S Phone -�� - <br /> IS CERTIFICATE OF WORKtiANIS C011PENSATIO'N TINSURANCE T1 FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL,R DEEPEN ❑ RECONDITION ❑ DESTRUCTION[ O <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER❑ .t. <br /> PUMP INSTALLATION jigPUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> �. DISTANCE TO NEAREST: SEPTIC TANK/A/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL ELD 1 CESSPOOL/SEEPAGE PIT OTHER <br /> FI <br /> PROPERTY LINE - PRIVATEDOMESTIC WELL a& =— <br /> — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation /a ," <br /> Industrial <br /> _Domestic/private _Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of CasingJe <br /> / <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection < Rotary Type of Grout eo <br /> Disposal Other Other Information , Y. <br /> Geophysical Surface Seal Instal ed b - �v <br /> 'PUMP INSTALLATION: Contractor - <br /> Type of Pump ep H-P' <br /> PUMP R L-AGEMENT: State Work Done <br /> t � <br /> r PUMP RFPAIR:r ❑State Work Done <br /> DESTRUCTTON OF WELL: Well Diameter 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 accordar <br /> ; with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loci <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> ' I his permit is issued, I shall <br /> certify that in the performance of the work for which t <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California . '' <br /> I WILL ALL A GR T ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ' SIGNED TILE- r DATE: <br /> DRAW PLOT PLN ON REVEE DE <br /> FOR DE ARTME T USE ONLY <br /> PHASE I lJ DATE / 7 <br /> �APPLICATION ACCEPTED BY <br /> AD017JONAL COMMENTS : <br /> I PHASE II GROL!T INSPECTION PHASE III FINAL INSPECTION <br /> r SPECTION BY Q DATF - INSPECTION BY D�EA2�gll��N� 2h <br /> �uW <br /> `IJ 1 4 7A Qnv q/7R - <br />