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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> P�FF!�CEUSE: 1601 E. Hazelton Ave. , Stockton, CA 95205 [Date <br /> it No. 3 0 <br /> Telephone: (209) 466-6781.. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Issued <br /> (f;omp l ete In Trip 1 i cate') <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 IV.r. ,,� &/TOWN �z�ocKcvv <br /> owner's Nam or Phone <br /> Address <br /> Contractor's Name License / Phone4/,�--2kld _ <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATION INSURAF,! E ON FILE WITH SJLHD? YES No <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION 0 DESTRUCTION[J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION EI PUMP REPAIR❑ PUMP REPLACEMENT EJ <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVY ---- ° , <br /> SEWAGE DIS POSA4 IELD CES-SP L/SEEPAPE PIT - OTHER <br /> PROPERTY LIN00 fPRIVADOMESTIC WELL_62�-�t PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing y b� <br /> Domestic/public Driven Gauge 'of Casing a &J A4, �N <br /> _Irrigation Gravel Pack Depth :of Grout SeaUV ' <br /> Cathodic Protection Rotary Type of Grout - •— <br /> Disposal Other Other Information f, �� <br /> Geophysical Sur`face.Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ....H.P. <br /> .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. ". 1 <br /> I WILL CALL A GROUT NS T N ROUTING AND A'FINAL INSPECTION. <br /> SIGNED TITLE: A agryDATE: <br /> -a* <br /> P L N ON REVS SE I E <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z 7 1wr 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINALINSPECTIO <br /> INSPECTION BY DATE INSPECTION BY C ice . DATE Za <br /> EH 14 26 Rev_ 9178 — - «o 0M I <br />