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SAN JOAQUIN LOCAL'HEAL'IH U1�)1RILI <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephoner (209) 4664781 <br /> Date Issued $r' 7 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> _ <br /> This Permit Expires 1''Year From Date Issued <br /> Complete In Triplicate <br /> Auplication 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 /> oaquin County Ordinance No. .1862 and the Rules -and Regulations of the San Joaquin Local Health <br /> :''.strict. <br /> EXACT:STREET ADDRESS CITY/TOWN S . La-,-) <br /> Owner's Name Phone <br /> Address F City � . <br /> Contractor' s Name License of Phone ^fi,_ 1ry7 <br /> TS_CGRT.iFICATE OF 140PK1iA?i'S4CO3",PENSATIOtJ I"!SURAINCE.ON FILE WITH SJLHD? YES _NO <br /> TYPE OF WORK (Check) :--NEW WALL Ci- DEEPEN ❑ _RECONDITION ® DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Cl OTHER ❑ <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENTJO <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - <br /> Irrigation— - ---,-Grave-1-Pack-�. De- tfi of Grout .Seal - <br /> k Cathodic Protection Rotary °Type of .Grout-t l <br /> Disposal Other Other Infor'�iation <br /> Geophysical 3 Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .., , ; H.P. <br /> PUMP REPLACEMENT: State Work DoneREvo' `c;` <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 5 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 accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 /> laws of California. " ' � = :% of " �. - <br /> I WILL CALL FOR ROUT INSPE IONPRIOR TO GROUTING AND A F AL INSPECTION. <br /> SIGNED TITLE: DATE: /0 - - <br /> (DRAW PLOT PLN ON REVERE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE W) <br /> ADDITIONAL COMMENTS: <br /> !,PHASE- II--'GROUT INSPECTION PHASE IIi INAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE& /20C <br /> k�pu 1 a9A Da,. 11_77 {, CP 117 8 2M <br />