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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466 .6781' <br /> 1 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete In Triplicate T, <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 /> �-oao4,>in County Ordinance leo. 1862 and the Rules and• Regulations 'o'f the San Joaqu:i-n Local Health <br /> EXACT STREET ADDRESS 3 ` I �, /�/�/ CITY/TOWN i <br /> Owner' s Name AZ-j: Phone 70 <br /> 670 <br /> Address SA!rM F, -— City <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO�1 INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ • RECONDITION Q DESTRUCTION) <br /> WELL CHLORINATION ❑# WELL ABANDONMENT ❑ OTHER❑ .� <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT I] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <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 I <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 <br /> yP pH.P. <br /> PUMP REPLACEMENT:REPLACEMENT: [] State Work Done . <br /> PUMP REPAIR: °w ❑State Work Done <br /> DESTRUCTION OF WELL: Well DiameterG� f" Approximate Depth 64 <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 /> y "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 o alifornia " <br /> 11 <br /> I WILL OR A GROU. I PECTION PRIOR TO GROUTING AND AJINAL INSPECTION. <br /> SIGNS TITLE: DATE: 7�3 <br /> DRAW PLOT PLN ON REVS SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE IIL YBAL I SPECTION <br /> INSPECTION BY DATE /ice --- INSPECTION BY DAT —S <br />