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SAN JOAQUIN .LOCAL..,HEALTH DISTRICT <br /> FOR-OFFICE USE: i 1601 E. Hazelton Ave.., ,Stockton, CA 95205 Permit No.2y <br /> Telephone:' (209) 466 -6781 <br /> '� Date Issued ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> r This Permit`Expiros', I'Year�Fr&m.Date Issued `- <br /> Complete Iri Triplicate <br /> Application is hereby made. to the San Joaquin Local Health Di.strict fora permit.,to.construct. <br /> and/or install. :the;°work herein described.. This_appljcation, is made in ,compl.iance with. San . <br /> Lloanuin County> Ordinance No. 1862 and the Rules and Regulations of the .San .Joaqu n,Local. Health <br /> D i s t r i c t <br /> EXACT STREE ADDRESS CITY/TOWN <br /> R, <br /> Phone - <br /> Owner' s NameAAl _ <br /> �: <br /> Address o � .._. . .. ... City <br /> Contractor's Name License# . � �_ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO'1 INSURA*10E T1 FILE WITH SJLHD? YES NO <br /> `TYPE OF` WORK (Check) : "NEW' WELL Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ U <br /> ( WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER 0 AZ <br /> I.PUMP INSTALLATION E3PUMP REPAIR PUMP REPLACEMENT Q C <br /> G-DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> # 1SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ OTHER <br /> I�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 /> I Domestic/public Driven Gauge of Casing <br /> Irrigation0 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: l�Contractor i <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT:' !! Q State Work Done <br /> rPUMP REPAIR: i (]State Work Done S- <br /> j DESTRUCTION OF WELL: - ' Wel..l. DiameterApproximat4 ept.h - <br /> Describe Material and Procedure <br /> ' I hereby certify that I have prepared this application and that the work will be done in accord <br /> .with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Lo <br /> Health District. Homellowner 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. , 6 <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED , I� TITL'E: DATE: <br /> �M (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP RTMENT'USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS : IN <br /> PHASE II GROUT INSPECTION PHASE III fINAL INSPECTION <br /> INSPECTION BY � _ DATE INSPECTION BY _ _- "� DATE <br /> .EH 1426 Rev. 1277, �. .� _� 1./_78, _ <br />