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SAN JOAQUIN LOCAL HEALTH DlS-I.RIC-1 <br /> -OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 952(} `�" ermit No. �. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued ,2—, <br /> This Permit Expires 1 Year From. Date Issued "(,0 II f-j <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for aerm't to const ct <br /> p <br /> and/or install the work herein described. This application is made in compliance with San <br /> 1oaa5��n County. Ordinance No. 1862 and the Rules and Regulations of the San .Joaquin Local Health <br /> District. �:. sO:S,. ; <br /> EXACT STREET "ADDRESS 1� `" `- )I � /CITY/TOWN -ss' <br /> Owner' s Name one ' _a d <br /> Addressr City ____ <br /> Contractor' s Name <br /> F , License# , L FY3 Phone <br /> IS CERTIFICATE OF WORKMAN COMPENSATIO"j <br /> T. <br /> URA"!CE ON FILE WITH SJLHD? YES NO ; <br /> TYPE OF WORK (Check.) : NEW[WELL DEEPEN [I RECONDITION ❑ DESTRUCTION E]WELL CHL RINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP: INSTALLATION E7 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE-TO- -NEAREST: SEPTIC- TANK SEWER LINES --� PIT PRIVY- <br /> T_ SEWAGE DISPOSAL CESSPOOL/SEEPAGE,.PIT--, -- OTHER a <br /> w,< _ PROPERTY LINE --. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <br /> Industrial Cable Tool Dia. of Well Excavation - �/, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven w . Gauge of Casing <br /> Irrigation Gravel 'Pack Depth of'Grout Seal <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information - M <br /> Geophysical Surface Seal Installed b -- <br /> PUMP INSTALLATION: ,Contractor F)(�'MJJ — <br /> ./Type of Pum % H.P. € <br /> PUMP REPLACEMENT: - Q State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate" Depth <br /> Describe Materia and Proce ure <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 k <br /> laws of California." 1 <br /> I. WILL CAL FOR A GROU INSPECTION PRIOR'' 0 GROUTING AND A FINAL INSPECTION. <br /> SIGNED Vf �- <br /> �( TITLE: DATE:2-Z-I <br /> DR W P,L.OT PIAN ON. REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III ,INAL INSPECTION <br /> INSPECTION BY DATE_ INSPECTION 8Y e, DAT£ ��� <br />