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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE .�SE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No, 7 _ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 7-/07 <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 2 ,,,,. _._. _ CITY/TOWN <br /> Owner's Name Phonea� -)- <br /> Address 6F3 9y91 Ci tyc �,�„�,� <br /> Contractor's Name Licensees ! Phone R��dZ$7 yG <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATi0,1 INSURANCE ON FIL£ WITH SJLHD? YES NO <br /> TYPE OF WORK_ (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE `1O NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER n <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 /> 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 0: <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 Proce ure <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 A GROU INSPEC ION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> S I <br /> TITLE: DATE:� -aZ <br /> (DRAW PLOT PLAN ON REV SE SIDE _ <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION c,�td�.. �ef.G; p�--- PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B � DATE/2 --r`7;�7 <br /> EH 1426 Rev. 12=77 1/78 2M <br />