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SAN JOAQUIN LOCAL HEALTH DISTRICT �--- <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No."7 q : ; � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - Z <br /> 22 <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 C�, <br /> District. (��( <br /> EXACT STREET ADDRESS__ gonen J e_ ��� CITY/TOWN] <br /> Owner's Name Phone <br /> Address cityr} <br /> Contractor' s Name Lo Athl 41 License#,2� 1, Phone��I . <br /> IS CERTIFICATE OF WORK"ZAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES � 0 <br /> TYPE OF FORK (Check) : NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION Rj PUMP REPAIR❑ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK/&'--. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL__.o__- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,ONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation fp <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 Surface Seal Installed by. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - 12 <br /> H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proce ure <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 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 /> 1 f Calif rnia. <br /> I WI CALL OR GR T INSP GTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR <br /> PLOT PLTN ON REVERS DE <br />)HASE I FOR DEP RTMENT USE ONLY <br /> UPPLICATION ACCEPTED BY DATE '? <br />%DDITIONAL COMMENTS: <br /> PHASE II , ROU INSPECTIO PHAS III INAL INSPECTION <br />-NSPEC26 v. DATE INSPECTION BY DATE <br />:H 14 26 Rev." 8 9/78 2M <br />