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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160' Hazelton Ave. , Stockton, CA 205 Permit No. /61 -1, /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 / �„�,, a <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 /> ,'oan.:in County Ordinance fro. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. �� n <br /> EXACT STREET ADDRESS /-�tl( CITY/TOWN <br /> Owner's Name C ,,,� �� � ,�, Phonhr .i u`! <br /> Address P� b , ox City <br /> Contractor' s Name (D Lk) /IJ License# 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 Cj OTHER ❑ <br /> PUMP INSTALLATION PUMP REPAIR❑ PUMP REPLACEMENT ❑ (j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C3 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN` -. 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 cS� <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: -r/&/- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump yH.P. [� <br /> PUMP REPLACEMENT: F] 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 accordant <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 GROUT INSPECTION P IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: S - Z `-1-7 <br /> DRAW PLOT PLAN- ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z� d <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I INAL INSPECTION - <br /> INSPECTION <br /> NSPECTION -INSPECTION BY DATE INSPECTION <br /> rii , A- n ... awe ..-. <br />