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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave: , Stockton, CA 95205 Permit No-7 9 3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued �5- ^7 <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 /> a+id/or install the work herein described. This application is made in compliance with San <br /> ,oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 0 0.0 € CITY/TOWN �g <br /> Owner's NameAT <br /> Phone ; <br /> r City <br /> Address 00 s -� <br /> Contractor' s Name ! License# Phone <br /> '.S CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJ1_HD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL(]''- DEEPEN [] RECONDITION ❑ DESTRUCTION n <br /> WELL CHLORINATION WELL ABANDONMENT 0 OTHER l- <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT p <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 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump N.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 accordant <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 !_ OUT INS, CTION PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGN TITLE: DATE: - Z <br /> (DRAW PEOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4. J <br /> APPLICATION ACCEPTED BY I Z17 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �,� ,DANE art-z. <br /> 1 /7A -9M, <br />