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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F��FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Perin1-1 Ne-. -71- jd/ga <br /> Telephone: ,, X20 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> �. This Permit Expires 1 Year From Date Issued <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 ADDRESS Iza,117.10CITY/TOWN <br /> Owner's Name - Phone � <br /> Address I City <br /> Contractor's Name �� License# f, /- Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSAT,110M INSURANCE ON FILE WITH SJLHD?�- YES-/ — NO <br /> TYPE OF WORK (Check) : NEW WELL-e DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION L PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <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 U <br /> Industrial Cable Tool Dia. of Well Excavation ,r <br /> ,>4��--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,_______Disposal Other Other Information 7, -- 77 : T .f <br /> GeophysicalSurface Seal Installed b /,�. rte, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _J.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION 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 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 subjectoto Workman' s Compensation <br /> laws of California. " ��.� <br /> I WILL CALL FOR A/GROUT INSPECTIO PRIOR TO GROUTING` AND A , NAL ISS°PECT,ION. <br />.SIGNED : ! .... n �` -- --.�._. T I TL E:-�`'.� .r A :' � `'r DATE: <br /> DRAW PLOT PL N ON RVERSE SIDE { f <br /> FOR DEP RTMEN- USE ONLY <br /> PHASE I f. .. _ <br /> APPLICATION ACCEPTED BY ,r + � `�_'"' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH.-•142F Rav 19_77 1 177 1)M <br />