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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, CA 95205 Permit No.Zg- <br /> jCar <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .'OR PUMP PERMIT Date Issued�p_� <br /> This Permit Expires I Year From- Date Issued <br /> Complete In Triplicate ' <br /> Application is hereby made to the San Joaquin' Local Health District fora permit to construct : <br /> and/or install the work herein described. This application is made in compliance with San <br /> ,'oan:.>in County Ordinance No. 1862 and the Rules and Regulations of the S,an Joaquin Local Health <br /> Distr'ct. <br /> EXACT STREET- ADDRESS _ p v/,_5- QTY/TOWN <br /> 5'��� �_Qrtc�_�� � <br /> Owner' s Name e e ��� _. PhoneR--' <br /> Address- Rd City. �-- —;_ <br /> Contractor's Name License Phone t <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA*10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ T <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION (;?L PUMP REPAIR❑ PUMP REPLACEMENT ❑ '� <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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information . <br /> Geophysical Surface Seal Installed b : <br /> IL <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump gn H.P. - <br /> PUMP REPLACEMENT: State Work D ne <br /> PUMP REPAIR: Q 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. " + <br /> I WILL CALL GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE : DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> rW Z AOC n.... 1 n -7'7 45740 rOm <br />