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SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , ,Stockton, CA 95205 Permit No. 7� <br /> Telephone: (209) ,466-6781 <br /> 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. 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 /> CITY/TOWN <br /> EXACT STREET ADDRESS 1 <br /> Owner's Name " L .�! Phone— <br /> Address' <br /> City K - <br /> Contractor's Name_ /� _ License# S(gZS7"` Phone <br /> IS CERTIFICATE OF WORKMAN'S C0,11PENSATIO`J IPISURANCE ONFILE_WITH SJLHD? YES NO <br /> TYPE. OF -WORK (Check)-:-- -NEW-WELL0--- -DEEPEN=p--YR°E-CONDITION ❑ DESTRUCTION - - - <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION Wr PUMP REPAIR 0 PUMP REPLACEMENT (� <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 vy <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N� <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 i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information t <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump "b, H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP, REPAIR: Q State Work Done. <br /> DESTRUCTION OF WELL: Well-Diameter _ Approxi.mate, Depth _-� _ _ _ <br /> Describe Materia ana Procedure <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 f <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: �� � <br /> DR W PLOT PLAN ON REVERSE SIDE) <br /> ---FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPL.ICATiON ACCEPTED i BY - DATE / <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION ` PHASE .LIX FINAL INSPECTION <br /> INSPECTION BY DATE IBC INSPECTION BY DATE f <br />