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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. U �- <br /> Telephone: (209) 466-6781Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Thi"s 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 3 <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,'oagsin County Ordinance-No. 1862 an Whe Rules and Regulations of ,the San Joaquin Local Health <br /> District,. 1 O <br /> EXACT STREET ADDRESS �� LEMCITY/TOWN <br /> Owner's Name -- y - — Phone $r3-!)`- W cab <br /> Address [ (�, ��� City - <br /> _ <br /> Contractor's Name_ LicenseL37t Phone $/_ " <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURAINCE 0P1 FILE WITH SJLHD? YES `5C NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR CK PUMP REPLACEMENT <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'Ca91-ng <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: 5(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 subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CA OR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED DATE:. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR D&PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYZa�lDATE <br /> ADDITIONAL COMMENTS : a a <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE( J� <br /> EH 1426 Rev,,. 12.�77 <br /> 1/7,8'"` 2M � <br />