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SAN JUAQUIN LUCAL HkALIH UIIKICI - <br /> FFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. � <br /> Telephone: (2090 466-6781 ' <br /> APPLICATION FOR' WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued _/ 7 S` <br /> This Permit Expires 1 Year From Date Issued <br /> Compl ete..In Tri pl i,cate <br /> Application is hereby made to the San :Joaq'uin Local Health District for a permit to- construct . t <br /> and/or install the workherein described. This application is made in compliance with San <br />.'oawjin County Ordinance 1o. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADD ESS CITY <br /> Owner' s Name .2 y Phone <br /> Address City <br /> Contractor's Name /-Li cense Phone /C� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA" E ON FILE WITH SJLHD? YES NO <br /> TYPE OF' WORK (Check) : NEW WELL10 DEEPEN ❑ RECONDITION ❑ DESTRUCTION[D <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER Q <br /> 3 PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT El <br /> DISTANCE °TO NEAREST: SEPTIC TANK S-e �-SEWER LINES6-Q fPIT PRIVY <br /> SEWAGE DISPOSAAt-FIELD CESSPOOL/SEEPAGE PIT/HCl-f-0THER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL��PUBLIC DOMESTIC WE <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS l <br /> Industrial Cable Tool Dia. of Well Excavations <br /> domestic/private fs /,-15r_i1_1ed - - D'ia. -of'Wel l Casing r� <br /> Domestic/public } , . Driven . Gaug—of_Casing 172Z2 4/z <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 by: <br /> PUMP INSTALLATION: Contractor A019y-,9ze&.e � yS <br /> Type of Pump H.P. .t�_ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: QS-tate Work Done <br /> DESTRUCTION OF WELL,: -,Well Diameter "` "` ' Ap:pr`oximate Depth <br /> Desdri-be-.Material and Procedure ." a <t,T,A s <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"Regul.ations of the San Joaquin Local <br /> Health District. Home owner or licdhsed-,agent' s signature certifies th(' foll'owing: <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 ta`Wo'kman s Compensation <br /> laws of California." -� '"' <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION-`.-.-- <br /> SIGNED TITLE: DATE: <br /> DRAW PLOT PLAN ON REVER 5ID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I --' !� <br /> APPLICATION ACCEPTED BY <br /> A -Z- DATE <br />'-ADDITIONAL COMMENTS : <br /> PHASE II T I S p�3� t PHASE III FINAL INSPECTION <br /> INSPECTION BYlj INSPECTION BY DATE <br />`EH 1426 Rev. 12-77 <br />