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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EQR, QFFICE USE: '' X1601 E. Hazelton Ave. ; Stoc+ton, CA 95205 Permit No._-$ - W-M <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> �-QT �� This Permit Expires 1 Year From Date Issued <br /> T 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 Z L.CJ / CITY/TOWN <br /> Owner' s Name Phone <br /> Address City <br /> Contractor' s NameLicense#2 Phone -5 031 <br /> IS CERTIFICATE OF WORKr1AN'S C0,1P SATIOr� IrJSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL V) DEEPEN Q RECONDITION C1 DESTRUCTIONE2 <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION C PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY VW <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- OTHER <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIF TIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 22- <br /> Irrigation <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 b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: CjState Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an 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 wo�ecome <br /> m f r which this permit is issued, I shall <br /> not employ any person in such manner as to sject to Workman's Compensation <br /> laws of Cal 'fornia. " <br /> I WILL CALL FOWA GROUT INSPE N PRIOR .TO GROUT ND FINAL I TION. <br /> SIGNED TITLDATE: 2 <br /> DRAW PLlz7y <br /> T PL N ON V E SIDE <br /> n <br /> FOR DEPARTMEN E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYL2��, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE - 7 INSPECTION BY DATE d <br /> EH 1426 Rev. 12-77 1/78 2M <br />