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SAN JOAQUIN LOCAL HEALTH DISTRIU <br /> FFICE USE: 160 . Hazelton Ave. , Stockton, CA 5205 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 3--� 77 <br /> This Permit Expires 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 Z,7,- Ewe a - t - )CITY/TOWN <br /> Owner's Name �� Phone�Y �� <br /> Address `� �-c� � . _ City <br /> Contractor's Namer/., License#:2,6c'4� Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ �y <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENTIV <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 /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical �i Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor. 1 1 <br /> Type of PuH.P. J <br /> PUMP REPLACEMENT: [] State Work Done <br /> PUMP REPAIR: ❑State Work Done <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 accordan( <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the San Joaquin Loca' <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 OUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ett, (�Q TITLE: DATE: <br /> DR W PL L N ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLYu,�, <br /> 13 g <br /> APPLICATION ACCEPTED BY / r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY elDATE <br />