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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —E0R OFFICE USE: 3.601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. f 4v <br /> - _ Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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. <br /> EXACT STREET ADDRESS <br /> CITY/TOWN <br /> Owner's Name <br /> Phone <br /> Address. - p City <br /> Contractor's Name �License� 3- ,3 Phone .2,l <br /> I5 CERTIFICATE OF WORKMAN'S COP�PFMTION._ INSURA"NCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check{).: NEW WELL Q DEEPEN RECONDITION D DESTRUCTION . <br /> ` WELL CHLORINATION WELL ABANDONMENT 0 OTHER 0 O <br /> x PUMP INSTALLATION Q PUMP REPAIR 0 PUMP REPLACEMENT ] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC D07ESTIC WE <br /> INTENDED USE * , TYPE OF .WELL_., CONSTRUCTION SPECIFICATIONS <br /> Industrial s - . 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 Sea ' <br /> athodic Protection Rotary Type of Grout. <br /> a Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMP:-REPAIR: QState Work Don <br /> DESTRUCTION ':OF WELL: Well Diameter t <br /> Approximate Depth ; <br /> De$cribe -Maierial and Procedure <br /> ' l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin CountyOrdinances 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 /> SIGNED TITLE: DATE: � .�r <br /> E DR �PL �TPL N ON REVERSE IDE <br /> F R P RT EN <br /> PHASE !I SE ONLY <br /> APPLICATION ACCEPTED BY/ f <br /> ADDITIONAL COMMENTS: DATE <br /> !� PHASE I GROUT INSPECTION4 <br /> PHASE III F AL INSPECTION <br /> INSPECTION BY s <br /> DATE INSPECTION BY DATE 1Z <br /> EH 14 26 Rev. / $ 9/7R <br />