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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.7g jb S'7 <br /> T1 61 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/,,7 <br /> This Permit Expires l 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 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 <br /> District. <br /> EXACT STREET ADDRESS /VF, CITY/TOWN <br /> Owner' s Name GC Phone <br /> Address V 7? Ci ty 6Aa::,&a <br /> Contractor's Name 6License## _2 0IFJA Phone — <br /> 9 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES f( NO <br /> TYPE OF WORK (Check) : NEW WELL(< DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ®` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Qf CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> — . 13.- 1-7 <br /> (_Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b—: ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> v <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 CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r TITLE: a�B,GCC.. DATE: <br /> (/ - (DRAW PLOT P N ON REVERSE SIDE <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I7f4ROUT INSPE ON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATES INSPECTION BY. (,. DATE 2 <br /> EH 1426 Rev. 12-77 1/78 —2M <br />