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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USt 1601 E. Hazelton Ave ' , Stockton, CA 95205 PermitsN . <br /> Telephone: (209) 466-6781 " <br /> 4 <br /> AP'PL`ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT nate Issued <br /> �L This Permit Expires 1 Year From Date ' lssue'd <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 CITY/TOWN <br /> .TL�� <br /> Owner' s Name 4i phone <br /> — (Z <br /> Address City <br /> Contractor's Name License# Phone -2-1. e - <br /> IS CERTIFICATE OF WORKMAN'S COMPEN ATION INSURA+ICE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL a bEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION E] 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 SPECIFIC INS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia:-of Well Casing <br /> Domestic/publiz Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. _�CRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proc_e ure <br /> I hereby certify that I have prepared this application and that the work will be done in rdance <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaqu�n Local <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the wor or whit is permit is issued, 3", 11 <br /> not employ any person in such manner as to ecome subject o Workman's Compensatio <br /> laws of California. " <br /> I WILL-CALL FOR A,GR9UT INSPECTION P TO GROUTIN ND A F ALNS TIO <br /> SIGNED TITLE: ATE• <br /> DRAW PL T PL N ON SE SIDE <br /> FOR DEPARTMEWr USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT CTION PHASE III FINAL INSPECTION. <br /> INSPE <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> a <br /> EH 1426 Rev. 12-77 1 /78 2M <br />