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`' ',- - -AAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. ?'I <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -1- 7 <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 CITY/TOWN <br /> -- ......_._....---- <br /> Owner's Name --- Phone 47 <br /> Address '" City <br /> Contractor's Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? Y 2., <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN Q RECONDITION Q DESTRUCTION[2 <br /> WELL CHLORINATION [3 WELL ABANDONMENT O OTHER f� - <br /> PUMP INSTALLATION [I PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SA—L IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL.- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In ustrial r Cable Tool Dia. of Wel Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ._Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <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 Done <br /> PUMP REPAIR: - CDState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth- - <br /> Describe <br /> epth Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> (URAW P N ON REVERSE SILE) <br /> PHASE I wFUR DEPARTMENT USE­ONLY <br /> APPLICATION ACCEPTED BY - " � DATE <br /> -7 { <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .EH 14 26 Rev. 9/78 9/78 2M <br />