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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> MR OFFICE -USE:, 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit lo. f::: . <br /> � Telephone: (209)- 466-6781x - <br /> APPL.ICATION FOR WELL CONSTRUCTION OR PUMPPERMIT Date Isued sZ <br /> This.- Permit .Ex fres 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 CITY/TOWN <br /> Owner's. Name 2 ,O - Phone 9,? _ 6'5� 1 — <br /> Address 7 � '"'' City <br /> Contractor' s Name c License#i q�7S- c Phone f � <br /> IS CERTIFICATE OF WORKiiAN'S CO"IPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL'Q DEEPEN ❑ RECONDITIONS] DESTRUCTION❑ <br /> WELL CHLORINATION E3 WELL ABANDONMENT Q OTHER 0 0 <br /> PUMP INS,TALLATIOPUMP REPAIR❑ PUMP REPLACEMENT Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN£ -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> -g Domestic/private Drilled Dia. of Well Casing ��' i <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 by: <br /> PUMP INSTALLATION: Contractor: <br /> Type of Pump H.P. • <br /> PUW REPLACEMENT: CIState 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 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 INSPECTIO_K,,PRIOR TO GROUTING AND A FINAL INSPECTION. <br />'SIGNED TITLE: ��. DATE:r <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE — <br /> ADQITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY- DATES`= -� <br /> /-70 OM <br />