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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F��FFICE USE: 1 1601 E. Hazelton Ave. , Stockton; CA 95205 Permit No. 2�3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issuedj , „ . <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 , <br /> 6 ,10 61 a CITY/TOWN c !cam i <br /> Owner's Name Z O Phone <br /> Address— �� �p � ' City Gam , <br /> Contractor's Name V. /C y�,,y �a,i„�' e Li cense# y 7 2,>2-�Phone 7- <br /> IS CERTIFICATE OF-WORKMAN'S COMPENSATION INSURANCE ON FILEWITH SJLHD? . YES NO­ <br /> TYPE <br /> "d <br /> TYPE OF WORK (Check) : NEW WELC4a EDEN CI�RECONDITION DESTRUCTIONE) <br /> WELL CHLORINATION Q WELL ABANDONMENT p -OTHER O- , <br /> PUMP INSTALLATION 0 PUMP REPAIR 0- - RUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK -mss- SEWER LINES - PIT PRIVY 'S <br /> SEWAGE DISPOSAL FIELD m- CESSPOOL/SEEPAGE PICS OTHER---0- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -$' PUBLIC DOMESTIC WE L - <br /> INTENDED USE' TYPE OF.WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Im!i <br /> Domestic/private __ rC Drilled Dia. of Well Casing, X <br /> Domestic/public Driven Gauge of Casing o pig A,<,, <br /> Al <br /> -,Irrigation _Gravel Pack Depth of Grout Sea <br /> _Cathodic Protection A <br /> __XRotary Type of Grout _g, • � I- <br /> Disposal Other Other Information <br /> ,,,Geophysical { <br /> Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.F. <br /> PUMP REPLACEMENT: ❑.State, Work Done - - - -� -- <br /> PUMP REPAIR: <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth � <br /> Describe Materi-a-T-a--n--d Procedure 1 <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'l 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 MILL CALL FOR A GROUT INSPECTI RRI.OR.TO GROUTING ANDA FINAL INSPECTION. <br /> SIG ._ <br /> NED � TITLE: . . : DATE: <br /> DTIFN ON REVERSE SIDE <br /> PHASE I 7 F R DEP RT EN USE ONLY <br /> PPS LICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY i DATE INSPECTION BY <br /> DATE <br /> EH 14 26 Rev. 9178 .. _.. <br />