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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�FTEESE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. S <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued d5` <br /> This Permit Ex 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 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 I_C7 m CITY/TOW07,0 C 0 <br /> Owner's Name--,D— . Phone�/V f <br /> Address ,Z t City Pe <br /> Contractor' s Name /I Li cen seg�ZP,16—'Phone /14/ -Al- <br /> TS CERTIFICATE OF WORKMAN'S COMPENSATION Ii1SURA"ICE ON FILE WITH SJLHD? YES NO L� <br /> TYPE OF WORK (Check) : NEW WELL❑ D£EPEN (4 RECONDITION ❑ DESTRUCTION[] <br /> V <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHERI_I � <br /> PUMP INSTALLATION q PUMP REPAIR 0 ' PUMP REPLACEMENT (� <br /> DISTANCE TO NEAREST: SEPTIC TANK la O 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 Z/ able 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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / �. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material ana 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r <br /> TITLE: DATE: � �� •� � � <br /> (DRAW PLOT PLVN ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III IINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> FH 1426 Rau 19_77 . 7 /7R 7M/ <br />