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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _FOR OFFICE USE: 1601 Hazelton Ave. , Stockton, CA 105 Permit No. � , - k S <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT (Date Issued <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 /> ,'oaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS l CITY/TOWN <br /> r_,��f,� <br /> Owner' s Name L/_AL1 F ,l) / s Phone <br /> Address—P,/-, Z 2 Ci ty^ZS;c� <br /> Contractor' s Name License# UK//y Phone y fj -�S1S <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION! INSURAINCE Oil FILE WITH SJLHD? YES X "10 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION 0 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT EJ- <br /> DISTANCE <br /> DISTANCE TO NEAREST: SEPTIC TANKS_ SEWER LINES 4 PIT PRIVY l5 <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE� - PRIVATE DOMESTIC WELL�2't PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation lf' <br /> Domestic/private Drilled Dia. of Well Casing 1,4 <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 As <br /> Geophysical Surface Seal Installed b ys <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: O 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 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 <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. " <br /> I WILL CA OR A GRWT INSP T ,ON � R TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE : �`� DATE: /E -�,t ,(� <br /> DR W PLOT PLT-N- ON REVE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATET��7/J <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIONBY DATE INSPECTION BY DATE �7, <br />