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J` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (2C -AW6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From 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 ;nstall 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 t' <br /> CITY;TOWN <br /> Owner' s Name PhorEe�f- � <br /> Address t Ile CityL� <br /> Contractor's Name t- License Phone <br /> IS CERTIFICATE OF WORKIMAN'S CO,ilPENSATIO'1 'ISURA'10E ON FILE WITH SJLHD? YES 1,10 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ® DESTRUCTION [] 17- <br /> WELL CHLOR NATION ❑ WELL ABANDONMENT 0 OTHER 0 _ � <br /> PUMP INSTALLATION 0 PUMP REPAIR E-J PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TAN�/�' SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT —OTHER <br /> PROPERTY LINE'04PRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> omestic/public Driven Gauge of Casing r.��c <br /> Irrigation _Gravel Pack Depth of Grout 5e-aT j <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal In talled by:,-IA <br /> PUMP INSTALLATION: Contractor J <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: []State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 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 CA FOR GROUT N EC I PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1 <br /> TITLE: ��,w� DATE: <br /> DRAW PL T PL N ON REVE SR�E IDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ` l/ <br /> ADDITIONAL COMMENTS : <br /> PHA E I GROUT INSPECTION HAS �FINAINSPECTION <br /> INSPECTION BYINSPECTION BY <br /> DATE �1- �8-'1$ <br /> FH 1426 Rav 1 _77 <br /> I /-7Q 7M <br />