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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazeltw Ave. , Stockton, CA 95205 Permit No. <br /> —, Telephone: ' .(209) 466-6781 <br /> p APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued '3I' <br /> This .Permit Expires 1' Year From Date Issued <br /> Complete_ <br /> In Triplicate �,/ / l/ <br /> Application is hereby made to the San Joaquin Local Health District for a permo. can ruc�t� <br /> and/or install, the work herein described. This application is made in compliance with San <br /> �'eaouin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> uistrct'� �� <br /> Z <br /> /�8ZID <br /> �t C� �_. .C_Sr�r�cr2 ,� f�O%t1 o3 <br /> EXACT STREET DRESS Z Z M. S (,5hD Lo TY/TOWN <br /> Owner' s Name (iR F �, Phone_ <br /> Address ! ' S- S M City 'cA(.v,✓ <br /> Contractor's Name N r7,4� License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? ' YES s NO <br /> TYPE OF WORK (;Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ hs <br /> WELL CHLORINATION 0 WELL ABANDONMENT © OTHER 0 _ <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT Ea <br /> DISTANCE TO NEAREST: SEPTIC, TANK SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY%, LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> �i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPE_C_IFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/pr,ivate Drilled Dia. of .Well Casing <br /> Domestic/public Driven - Gauge 6f Casing <br /> Irrigatlion Gravel Pack Depth of Grout Seal <br /> Cathodic' Proteeti on Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical � urface Seal Installed b <br /> PUMP INSTALLATION: Contractorr <br /> � <br /> Type of Pum � ��� <br /> yP p H.P. Lo 0 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: []State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> i��2S- Describe Material and Procedure <br /> I hereby certify th t I ave prepared this application and that the work will be done in accordand <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 employlany 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 /> SIGNED TITLE: DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> !� FOR DEPARTMENT USE ONLY <br />'HASE I <br /> APPLICATION ACCEPTED BY DATE 7t <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION 6 <br />'L[ l A7c ... nr__ t�.n -._ <br />