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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FICE USE: P 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 <br /> Telephone:- (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 Sa:n Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ., e?..o CITY/TOWN A-t��U. <br /> fOwner's Name .. '' _ Phone <br /> Address --- QJ? Z:7� <br /> lContractor's Name LicensePhone --m -� r <br /> ,IS CERTIFICATE OF WORKMAN'S COM EN ATION INSURAINCE ON FILE WITH SJLHD? YES XZ NO <br /> TYPE _OFWORK (Check) : NEW WELL 0 DEEPEN 0' RECONDITION ® DESTRUCTION 0 <br /> WELL CHLORINATION Q WELL ABANDONMENT 0 OTHER 0 -, <br /> PUMP INSTALLATION M PUMP REPAIR O PUMP REPLACEMENT [� r <br /> bISTANCE TO"NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESM'L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.- of Well Casing - <br /> =L-�_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 /> T Geophysical Surface Seal Instal ed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> 'PUMP REPLACEMENT: Q State Work Done u <br /> PUMP. ]State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material an2 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 Regulati-ons 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 IN TI N IO TO GROUTING AND A-FINAL INSPECTION. <br /> SIGNS TITLE: DATE: d <br /> _L_.IDRAW PLOT PL4NVON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEZ 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C• '3. DATE /- 3 <br /> EH 14 26 Rev- .9/7R - 9I7R 2M <br />