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= SAN JOAQUXN_LUCAL HEALTH DI51k1CT <br /> OFFICE USE: 1601 E. Hazel-,on4;e*. , Stockton, CA 95205 Permit No.z9 <br /> Telephone: ._ (209) 466-6781 <br /> Date Issued /-Z,6-22_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This '-Permit Ex ires- 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 4- <br /> and/or install the work herein described. This.application i.s made in compliance with San <br />, ,'oanvin County Ordinance No. 1862 and the Rules -and Regulations of the -San. Joaquin Local Health <br /> Cistr�ct. ` <br />( EXACT STREET ADDRESS <br /> CITY/TOWN , <br /> Owner' s Name Phone <br /> Address ! v City <br /> S <br /> Contractor's Name` License# Phone <br /> IS CERTIFICATE OF.WORKMAN'S C MPENSATION INSURANCE ON FILE WITH SJLHD? YES ✓ NO <br /> TYPE OF WORK (Check) : NEW WELL E!r DEEPEN ❑ RECONDITION.[3 DESTRUCTION[] <br /> WELL CHLORINATION Q WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT L <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 i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Cali iig <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection t, F6tary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type ofPump H.P. <br /> s. <br /> PUMP REPLACEMENT: []State,Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Ma' terial and Procedure <br /> a <br /> I hereby certify that I have l prepared .thi s�t appl i cati on.-a.nd--..that-the-work will be done in accordanc <br /> with San Joaquin County Ordinances', State laws , and Rules and Regulations of the San Joaquin Local <br /> tiHealth 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._is.sued_,-O steal1 <br /> i not employ any person in such manner as to become subject to Workman' s Compensation <br /> lawslifornia." f <br /> I WILL ALL F R A GROUT GPECTI RIOR TO GROUTING ANFINAL INSPECTION. <br /> ` SIGNED TITLE• rt1 DATE: dl�,�' <br /> } (DRAW PLOT PLAN ON RE ERE IDE <br /> E <br /> FOR DEPARTMENT USE ONLY „� <br /> PHASE I. � DATE�� <br /> APPLICATION ACCEPTED BY <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION- .� ----PHASE- 14-I-F--NAL---INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BYI ICU <br /> 1 /78 _ <br />