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SAN JOAQUIN LOCAL MLALlH UIS�RILI L' NOFQR FFICE USE: 1601 E. Hazelton Ave. , 'Stockton, CA 95205Telephone: (209) X66-fi781 ssued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit' Ex ires. l Year From Date Issued <br /> Complete In 1 ri p1 i cate <br /> hereby made to the San�Joaquin Local Health District for a permit. to construct <br /> Application is Y application is made in compliance with San <br /> and/ar .install the work herein described. This app <br />,'oaqui n County-,Ordinance No . 1862 and the. Rules and Regulations ,of the San Joaquin Local Health <br /> District. - <br /> } CITY/TOWP� <br /> EXACT- STREET ADDNSI S p <br /> E � Phone �1 . <br /> Owner' s N e <br /> City <br /> AddressT� Phone�3`��`Jyice, <br /> Litens <br /> Contractor' s Na e. ` <br /> D? YES N <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"t INSURANCE ON FILE WITH SJLH <br /> 6 <br /> TYPE OF WORK (Check) : NEW WELL M DEEPEN ❑ RECONDITION T DESTRUCTION <br /> WELL CHLORINATION f] WELL ABANDONMENT p OTHER a <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT <br /> IDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled. Dia. of <br /> � Well Casing s <br /> flomestic/pryvate Driven _ . Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> Irrigation Gravel Pack p <br /> Ro y Type of Grout <br /> Cathodic Protection O he ___� Other Information <br /> Disposal - Surface S a Installed b ' <br /> Geophysical <br /> PUMP INSTALLATION: Contracto � °-� H,P, <br /> Type of Pump <br /> IPUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> Approximate, Depth. <br /> DESTRUCTION OF WELL: Dell scribemMateria and Procedure <br /> I hereby certify that I have prepared this application and that the works illthe be donne eJin ac coLocal <br /> (,.with San Joaquin County Ordinances , State Laws , and Rules and Regulations <br /> Health,District. Home owner oro icensed 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 alifornia." <br /> I WILL CA FOR A OUT INSP T N P OR TO-.GROUTING AND F NAL INSPECTION. } <br /> - SIGNED <br /> TITLE: DAT <br /> DR W PLOT PL N ON_.REV- E :SIDE <br /> FOR DEPARTMEN USE ONLY <br /> cPHASE I DATE S 7� <br /> APPLICATION ACCEPTED BY m <br /> ADDITIONAL COMMENTS: - PHASEIII FINAL INSPECTI <br /> PHASE I1 GROU INSPECTION DAT <br /> INSPECTION 8Y DATE Y INSPECTION BY �f 5 <br /> _.. '7r6 if y � 1/.7 8 2M <br /> 1 n <br />