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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> OFF ICE USE: 1601 Hazelton Ave. , Stockton, CA 05 Permi t No. <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 �2 , p'r, `X� -j'= CITY/TOWN <br /> Owner's Name ��c� �� ; - 1e-eI z� Phone. — <br /> Address 4 c.` . i_- f, < City ev f <br /> Contractor' s Name �� % �,1 �� =� `S License0,1c,L67 Phone X-9_'-- Z,�,II.l --IS CERTIFICATE OF WORKIMAN'S C01,1PENSATIO"1 INSURA"10E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ® DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ED OTHER 0 <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENTJV <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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor�� c Type of of Pump <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 herebycertifyhat I have prepared this application and that the work will be done in acco <br /> rdanc <br /> P P PP <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 HOUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED a2�Q TITLE: DATE: <br /> DRAW PLOT PEM ON REVERSE SIDE <br /> FOR'DEPARTMENT USE ONLY <br /> j PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INVECTION PHASE III FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE / Y <br /> - <br />