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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. Stockton CA 95205 Permit No- -7&,&#6 <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/a-3- - <br /> This Permit Expires l Year From Date Issued ` <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health Districtfor 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 � . p d Phone — - <br /> Address City C t <br /> Contractor's Name c License# 0 7 Phone:jj� 'i 1 <br /> IS CERTIFICATE OF WORKMAN'S CO""PENSATIOIN INSURANCE ON FILE WITH SJLHD? YES I10 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION C] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ 14EtL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY L4 <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/privateDia. of Well Casing <br /> _Drilled r <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 /> EDESTRUCTION 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 G OUT NSPECTION PRIOP TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED P TITLE: DATE: <br /> DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATEC1— <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE�d <br /> .. _.. �., 1 1 7 ?M <br />