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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date IssuedY <br /> This Permit Expires l Year From Date Issued <br /> (Complete In Tri-plic—at—eT SCANNED <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 CITY/TOWN ° <br /> Owner's Name <br /> Address 2 .5 Qu 7-14 City s7_0C1r1_ jj <br /> Contractor's Name CE /E , f /11License#� Phone 5� <br /> IS CERTIFICATE OF WORKMAN'S COIMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN 0 RECONDITION ESTRUCTIONX <br /> WELL CHLORINATION 0 WELL ABANDONMENT OTHER( <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PU P REPLACEMENT 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES±:F _ 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 T <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor y. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Ap roximate Depth���— <br /> Describe Materia an 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 PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED : TITLE: DATE: <br /> (DRAW PL T PL N ON REVERSES DE <br /> PHASE I F R P RT ENT USE ONLY <br /> APPLICATION ACCEPTED BY �` DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION INSPECTION BY___j;�� PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 1426 Rev. 12-77 -�_ ` 1/�p 2M <br />