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SAN JOAQUIN LOCAL;HEALTH DISTRICT <br /> FFICIE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 - Pt rmit,,No. t' 3 <br /> Telephone: (209) 466,-6781 <br /> hL <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued Zf <br /> This Permit Expires 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. p <br /> EXACT STREET ADDRESS Ja I - CITY/TOWN <br /> Owner's Name f Phone <br /> Address ?0 City <br /> Contractor' s Name _ °�. „.,, / _ _ Li cense# ZJPhone .� <br /> IS CERTIFICATE OF WORKMAN'S CO!1PENSATIO I1111SURAINCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL'❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> T-� --- -.-WELL CHLOR-INAT-ION-E1- - WELL ABANDONMENT-0 OTHER I7 <br /> PUMP INSTALLATION Ga-- PUMP REPAIR El PUMP REPLACEMENT <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,n <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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical __ (� �. ._ „s � n .Su.rface__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 /> 4 <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 accordant <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 /> i laws of California. <br /> I WILL CW FO _A GRO__ INSPECTI PRIOR TO GROUTING AND-A FINAL._-INSPECT ION._--. .� <br /> SIGNED TITLE: DATE: <br /> W PLOT PLKN__ ON REVERSE IDE <br /> FOR DEPARTMENT E ONLY <br /> PHASE I <br /> lz <br /> APPLICATION ACCEPTED BY r -• DATE <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �. INSPECTION BY 0 DATE <br /> 1 ,1-70 OM - <br />