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CO tt It, -4N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601"- r. Hazelton Ave. , Stockton, CA '205 Permit No.z <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Exires 1 Year From. Date Issued <br /> Complete In Implicate <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 ' D Vo Alt K1 Qf'l( CITY/TOWN erive <br /> h <br /> Owner's Name Phone <br /> Address d ,/ City �/C <br /> Contractor's Name License# /G3-)vrPhone l�1 - 7L7L� <br /> IS CERTIFICATE OF WORKMAN'S COt1P IOtl INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL C1 DEEPEN 0 RECONDITION Q DESTRUCTION[2 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIRCO PUMP REPLACEMENT 0 <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 /> yIrrigation 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 <br /> Type of Pump ti H.P. Ty, <br /> PUMP REPLACEMENT: FIState Work Done <br /> PUMP REPAIR: (State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MateriaT—a--n-a Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 INSPECT N PRIO TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TLE: DATE: s 40N 04 hl 7 <br /> W PLT PLAWUN REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /J <br /> TP—PLICATION ACCEPTED BY DATE 1641-P -7 17e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO1 PHASE III FINAL INSPECTION <br /> INSPECTION BY_ DATE INSPECTION BY DATE <br /> ru ieoc n. ,n 7� <br />