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1 — SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, CA 95205 Permit No.7 L 7/b ._ <br /> Telephone: . (209) 466--6781 <br /> 7" <br /> APPLICATION FOR WELL CONSTRUCTION OR.PUMP PERMIT <br /> Date Issued s s <br /> This Permit Expires 1 Year From Date Issued <br /> s a 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 /> 2oacaui n County Ordinance No'. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. , <br /> EXACT STREET ADDRESS t CITY/TOWN <br /> Owner.'s Name Phone <br /> Address O • p City <br /> Contractor's Nam <br /> License# 71 Phone t <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN I'NSURAtaCE ON FILE WITH SJLHD? YES NO <br /> TYPE 'OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION Q DESTRUCTION Q <br /> WELL CHLORINATION Q WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION I PUMP REPAIR 0 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 "l7 <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 E <br /> Disposal Other Other Information <br /> Geophysical .. Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work DoOz <br /> PUMP REPAIR: []State Work Done <br /> i <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 th'e 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 ROUT ;NS ECTION PRIOR TO GROUTING AND A FINAL INSPECTION. v <br />°SIGNED TITLE: <br /> DRAW PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE. ONLY <br />'PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />`ADD'ITIONAL COMMENTS: <br />€ PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIi�A4- <br />'INSPECTION BY DATE INSPECTION BY DATE -- <br />