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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2 9�S2-,5-_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 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 P �� l' CITY/TOWN <br /> Owner's Name Phone 5 g�_ /.�;J <br /> Address C' -s 2-J Ci ty "j <br /> Contractor' s Name �� -e c �. icense# Phone 4� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'N INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) NEW WELL 0 DEEPEN ❑ RECONDITION p DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP ,INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT [I � <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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 47 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed <br /> PUMPContractor <br /> �, Type of Pump .P. <br /> PUM REP NT: ]State Work one ` <br /> PUMP REPAIR: ❑State Work Done. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an 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 G NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DAT ` <br /> DRAW PLGT PLN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE r <br /> APPLICATION ACCEPTED BY DATE 2, _ <br /> ADDITIONAL COMMENTS: <br /> PHASE' II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 142 . R - .x./78 <br />