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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _c3 <br /> Telephone: (209) 466-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/ , - , <br /> This Permit -Expires 1 Year From Bate ,Issued <br /> Complete In Triplicate) <br /> Application is hereby made to the ^San Joaquin Local Health District fora permit to construct <br /> and/or install the work'Mherein described: ,This application is' made in compliance with San <br /> Joaquin County Ordinanc` No. 1862 and,& Rules and Regulations of the San Joaquin- Local Health <br /> District. <br /> EXACT STREET ADDRESS l CITY/TOWN <br /> Owner's Name Phone <br /> Address City <br /> Contractor' s Name �?? License#A��v& Phone�-_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES �NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION (] DESTRUCTION d <br /> ° WELL CHLORINATION Q WELL ABANDONME p OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIRV PUMP REPLACEMENT [I <br /> r <br /> DISTANCE TO NEAREST: ASEPTIC 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 �p TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 <br /> Disposal Other Other Information <br /> Geophysical p Surface Seal Ins 1 ed b : <br /> PUMP INSTALLATION: Contractor j_,/ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: (] State -Work Done <br /> PUMP REPAIR: i Mate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <br /> E <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 Loca' <br /> Health District. HomelNowner 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 Californiall" <br /> I WILL CALL FOR A GR T INSPECTION PRIOR TO GROUTING AND A.FINAL INSPECTION, <br /> SIGNED .F. TITLE: DATEc, �', <br /> �l <br /> (0RAW PL T PL N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I� <br /> APPLICATION ACCEPTED BY DATE -- <br /> , ADDITIONAL COMMENTS: 11 <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY 11. DATE INSPECTION BY DATE <br />