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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.2 <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPPERMIT - t <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 A RESS 4/6 q CITY'/TOW. <br /> Owner's Name Phone <br /> Address - <br /> (, City <br /> Contractor' s Name License#Z Phone y <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIONT11SURAINCE ON FILE WITH SJLHD? YES � NO <br />-TYPE_OF"WORK (Check)_: NEW WELL L) DEEPEN 0 PRECONDITION Q DESTRUCTION( <br /> -.. - _-WELL-CHLORI.NAT.I-ON Q ---'WELL -ABANDONMENT,p_r. OTHER-0 .--- - <br /> PUMP INSTALLATION Q PUMP REPAIR W 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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor 4 1,23 � <br /> Type of Pump H.P. <br /> PUMP REPIXEMENT: �` -`p State work ^Dane <br /> PUMP REPAIR: []-State Work Done�� � � ; I�L_, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <br /> 3 . <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 Af the San Joaquin Local . <br /> Health District. Home owner or licensed agent's signature certifies the fallowing: <br /> "I certify that in the performance of the work for which this permit isissued, 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 CALVITPR A GROUT -IN ECTION PRI TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED '- .. TITLE: DATE: r- <br /> ' RAW PLOT PLAN ON REVERSE DE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - E <br /> APPLICATION ACCEPTED-BY . _ DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE k--'A IS <br />=H 1426_- -Rev. 12-77---- --. - 7 /7,q 9M t <br />