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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7q -59 <br /> Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued b / �! <br /> (Complete In Triplicate) <br /> - <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 e CITY/TOWN <br /> Owner's Name Phone <br /> Address City, <br /> Contractor's Name cS ® - License# Z2�-7 'Phone � <br /> IS CERTIFICATE OF WORKMAN'S rnmp SA ION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN C1 RECONDITION DESTRUCTION , <br /> WELL CHLORINATION 0 - WELL ABANDONMENT Q OTHER ( <br /> PUMP INSTALLATION Q PUMP REPAIR OD PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPYL/SEEPAGE P— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> X 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 H.P. —>W <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: QState 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 accordanc <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 INSPEC 0 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TLE: r'"' DATE: ra <br /> DR W PLOT ON REVER E .SIDE <br /> R DEPARTMEN USE NLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � a, . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III ! INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. 9/7$ 9/78_ 2M <br />