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N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FENCE USE: 1� '� 1601 E. Hazelton Ave,. , <br /> Stockton, CA 95205 Permit No. <br /> Telephone: (209) 466-6181 <br /> P CONSTRUCTION OR PUMP PERMIT Date Issued <br /> APPLICATION FOR WELL 0 <br /> This Permit Expires 1 Year From Date Issued <br /> 1 - Complete n Tri p i cate ' <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 Ordinanc0 No. 1862 and the Rules -and Regulations of the San Joaquin Local Health <br /> District. <br /> ,EXACT STREET ADDRESS CITY/TOWN <br /> Owner's Name - ,,..�., •�/,�, � � <br /> Phone �-- <br /> Address City %�C <br /> Contractor's Name 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 ( ] <DESTROCTIM[M"? <br /> WELL CHLORINATION] WELL ABA D NMENT ] -R- <br /> ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ 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 ; Drilled Dia. of Well Casing <br /> Domestic/public ;j 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 /> k Geophysical Surface Seal Instal ed b : <br /> PUMP INSTALLATION: Contractor <br />' Type of Pump H. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ;OState Work Done <br />' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <br /> I hereby certify that I 'have prepared this application' and that the work will be done in accordance <br /> with San Joaquin CountyOrdinances, 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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED TITLE: DATE: _ <br /> �DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I� <br /> FOR DEP TMENT USE ONLY� � 3 � <br /> AP-PLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSP TIQ.N�- SfAIIPECT "O <br /> INSPECTION BY A INSPECTION _ DATE <br /> 7 ti _ 2M.�- <br />