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SAN JOAQUIN LOCAL HEALTH DISTRICT -----�-- <br /> FOR FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (200) 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 /> ,'oan,>;n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distract. <br /> EXACT STREET ADDRESS ,? G � w • CITY/TOWN <br /> Owner's Name t (_l�F (2 t-4 �� c, Phone <br /> Address 2S. 0 2� City <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 Cl DEEPEN ❑ RECONDITION ❑ DESTRUCTIONS <br /> --- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT C3- <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑State Work Done Y <br /> DESTRUCTION OF WELL: Well Diameter 2 G Approxim to Depth <br /> bescribe 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 Calif nia. " <br /> I WILL CALL FOR ROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: s- <br /> (-DRAW PLICT PLAN ON REVERSE SIDE <br /> FOR DEPARTMEK USE ONLY <br /> PHASE I <br /> APACCEPTED BY DATE—PLICATION . <br /> ADDITIONAL COMMENTS : iz <br /> PHASE II GROUT INSPECTION PHASE III ,SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY4 DATE <br /> EH 1426 Rev. 12-77 1/78 2M <br />