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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FR 0 FICA USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209)_ 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued [,_s 9-?� <br /> t <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 I. <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS /14 19Atzls- ea. -- - CITY/TOWN Z=6) <br /> Owner' s Name n'I1? �` 1�� _�'u!I G Phone 'T,4 "t-a 3 0 z <br /> Address �_9_!J!S a - - — City G4 <br /> Contractor' s Name License# Phone_ -_-_ <br /> IS CERTIFICATE OF 0RK'iAN'S CO1,PENSATIO'NN'SURA.NCE ON FILE WITH SJLHD? YES N � 1 <br /> a <br /> TYPE OF WORK (Check) : �EW WEL C.1 DEEPEN ❑ RECONDITION A DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION (3 PUMP REPAIR❑ PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK / �LD , 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 /> Industrial Cable Tool Dia. of Well Excavation - <br /> . ► Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 5 <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 ,�1- <br /> Type of Pump SO b &II H.P. <br /> -PUMP REPLACEMENT: State Work Done <br />--PUMP REPAIR: ❑State Work Done <br /> kDESTRUCTION OF WELL: Well Diameter x Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be*one in acrdani <br /> with San Joaquin. County Ordinances , State Laws , and Rules and Regulations of the San,_Joaqulin Local <br /> Health District. Home owner or licensed agent' s signature certifies the follo`ving" I <br /> "T certify that in the performance of the workdfor which thi.s permit is i;5 sued: I shall; <br /> not employ any person in such manner as to became subject to Workman' s"'Compensa n <br /> laws of California . " <br /> I WILL CALL FOR A GROUT INS EC ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED , TITLE .DATE: *6 <br /> DR W PLOT PLAN ON REVERSE SIDE ' <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � - � � DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION / PHASE III FINA INSPECTIO <br /> INSPECTION BY XI: iDATEINSPECTION BY E OP <br /> 2M ' <br />