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✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE 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 /2-,�2 G- <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 Y CITY/TOWN <br /> Owner's Name CZ `� Phone 3 <br /> Address '� Qe ' City�r -, -- — <br /> Contractor' s Name License# I111,�QO Phone <br /> IS CERTIFICATE OF WORKMAN'S CO"PENSATIO�! I'ISURA"ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELD} DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION 14 PUMP REPAIR❑ PUMP REPLACEMENT E] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY c� <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 C <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: LA ` <br /> PUMP. INSTALLATION: Contractor r1 <br /> Type of Pump �. H.P. <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑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 accordancf <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 /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> goo SIGNED TITLE: DATE: <br /> DRAW PLOT PL N ON REV RS IDE ' <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: �pJ <br /> PHASE II GROUT INSPECTION PHASE III FIRL INSPECTION <br /> INSPECTION BY DATE INSPECTION By/—e DATE <br />