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` SAN JOAQUIN LOCAL HEALTH C11S1K1C1 <br /> OFFICE 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 , <br /> This Permit Ex ires 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 e R � e and. Reg t' sof the .San Joaquin Local Health <br /> , <br /> District. � Y <br /> EXACT STRfT DDRESSr � . CITY/TOWILQN <br /> Owner's Name y114 ,,k_- �r �u rz Phone <br /> Address Ci ty,S" �. a�., <br /> Contractor's Name License# Phone_P," -2 EJ l ^ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> 01 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS-OL/SEEPAGE PT OTHER <br /> 10 PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation AA/.(- 4 <br /> Domestic/private Drilled Dia, of Well Casing " <br /> Domestic/public Driven Gauge of Casinza <br /> g <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other InformationOL, <br /> Geophysical Surface Seal Ins <br /> ta e b � ,� <br /> PUMP INSTALLATION: Contractor <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 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 CALL FOR A GR UT INSRgCT/19NFVOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: k DATE: <br /> tUKAW PLT PLTN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY T--C DATE 8=? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 111 FINAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY DATE 79 <br /> Fw 1A7F Do., 19_77 1 r7Qc <br />