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SAN JOAQUIN LOCAL -HEALTH DISTRICTEQR Permit No. 6 <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date IssuedZ0,- �,7 7� <br /> This Permit Exp ires 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 heretin 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 /> Oistr�ct <br /> EXACT STREET ADDRESS ' • . <br /> CITY/TOWN_Q4 <br /> Owner' s Name. . r Phone <br /> Address 22 <br /> City .. <br /> Contractor's Nam _ <br /> License#31 Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"J INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN d RECONDITION ❑ DESTRUCTION[1 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 MP REPLACEMENT <br /> CI <br /> PUMP INSTALLATION N PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t <br /> PROPERTY LINE . PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 37(_Domestic/private Drilled Dia. of Well Ca— <br /> Domestic/public Driven Gauge of Casing <br /> 4 Irrigation Gravel Pack Depth of Grout Seal <br /> I Cathodic Protection 1Rotary Type of Grout <br /> Disposal + Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Cont'ractor. <br /> Type 11of Pum H.P. <br /> rPUMP REPLACEMENT: ❑State Work Done <br /> t <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: W61 DTame ter - " Approximate-Depth <br /> Describe Material and Procedure <br /> fI hereby certify. that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <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 CA GRO T N PECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: DATE: <br /> DR W PLUT PL N ON REVERSE SIDE <br /> FOR DEPT—R11'', NT USE ONLY <br /> PHASE I DATE/— <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : i� <br /> PHASE II GROUT INSPECTION PHA I I AL INSPECTI. N <br /> INSPECTION BY ' DATE INSPECTION BY DATE --�/v -� <br />