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SRN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: P/ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Telephone: <br /> Telephone: . (209)- X66-678I <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I 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.. <br /> D4str�cThis application .is made in compliance with San <br /> uoafjDistr, County ,C?rdl,ndnce No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> t. ", <br /> EXACT STREET ADDRESS 7 (� CITY/TOWN Z <br /> Owner' s Name 4 Phone <br /> Address. City <br /> Contractor' s Name e License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOIN INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN 0 RECONDITION ❑ DESTRUCTIONN u <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION [I PUMP REPAIR❑ PUMP REPLACEMENT [� s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 E> Gravel Pack,. Depth of Grout Seal I <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information "! <br /> Geophysical Surface Seal Installed-by. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. � <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1169 <br /> Describe Materiaand Procedure Approximat Depth <br /> T <br /> G � <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 INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br />:SI:GNED TITLE: DATE: fl-N-79 <br /> DR W PLOT PL N ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY �' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE l �� <br />-H 142h Paw 17_77 <br />