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XSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. - <br /> Telephone: (209) 466-6781` <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Perm it `Expires 1 Year From Date Issued <br /> Complete In Triplicate ' <br /> Application is hereby made to the San Joaquin Local Health District for 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 an4 the Rules and Regulations of the San Joaquin Local Health <br /> District. /V. <br /> • d <br /> EXACT STREET ADDRESStl <br /> vk1 x'04- c.N��. CITY/TOWN <br /> Owner's Name Phone <br /> Address P -70 !/ � .r ,x ', C i ty -D! ",•,.� <br /> Contractor's Name License# lGJ3y ,f=Phone �tGZ -76 74=0 <br /> IS CERTIFICATE OF WORKMAN'S rigP46TIO1111 INSURAINCE ON FILE WITH SJLHD? YES X 1110 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Ljc <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 /> Domestic/private Drilled Dia. of Well Casing_ <br /> Domestic/public Driven Gauge of Casing <br /> k 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 k H.P. 7x— <br /> PUMP REPLACEMENT: State Work Done -QAji=Lt / <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 /> laws of California." <br /> I WILL CALL FOR A GROUT INSPECTION- PRL08 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> R W T PLRN ON REVERS SIDE <br /> PHASE I FOR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY rDATE <br /> FH 1426 Ppv- 19-77 1 8 2M <br />