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T' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE• 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No: -� <br /> Telephone: (209) 466--6781 Date Issued S_-,2--7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex ires 1 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 /> EXACT STREET ADDRESS_ � ,��' /eS� n• CITY/TOWN ---- <br /> Owner' s Name , Phone <br /> Address_ City <br /> Contractor' s Name 0&A)AI F R License# Phone <br /> IS CERTIFICATE OF WORKtIAN'S C01IPENSATIO"! I'NSURA"10E ON FILE WITH SJLHD? YES N <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION Q DESTRUCTION ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR 04 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well -Excavation,--- <br /> Domestic/private <br /> Excavation----Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 <br /> Type of Pump H .P. 4Q <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done f�C� ��f�/-41" e, D <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accorc <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Lc <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 I WILL CALL FOR A GV.44VT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED / TITLE : DATE: <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTM NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY C 7 DATE _7 � � <br />