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L/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton M. ,"Stockton, CA 95205 Permit No. , <br /> Telephone: (209) 466-6781 <br /> Date Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Expires I. 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 /> Joaquin County Ordinance 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 Phone 1? <br /> Address City C A411A AJ <br /> Contractor' s Name Licensee/9-_- Phone ?!V _2P116 <br /> IS CERTIFICATE OF WORKMAN'S C0IMPENSATION IPISURA"CE ON FILE WITH SJLHD? YES k NO <br /> TYPE OF WORK (Check) : NEW WELL OO DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ A:� <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q N <br /> DISTANCE TO 'NEAREST: SEPTIC TAN Q 1 SEWER LINE/-L PIT PRIVY <br /> SEWAGE DISPSO ALFIELD -- CESSPOOL/S EP/4GE PIT -- OTHER--- <br /> . PROPERTY LINf�94PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL --==— <br /> INTENDED <br /> ELL tiINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation_� 'f <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 ProtectionRotary Type of Grout <br /> Disposal Other Other Information " 42 <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Q State Work Done <br /> PUMl?__RE-PAI-R: ---_.,., QState Work Donk r <br /> DESTRUCTION OF WELL: ell Diameter &11) Upproximate Depth <br /> Describe 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 California. " <br /> I WILL CA FOR A G UT IN 'EC ON OR TO GROUTING AND A FINAL INSPECTION. } <br /> SIGNEDTITLE: [A DATE: �,N <br /> D W PLUT PL TNON REVS S SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 4 " <br /> ADDITIONAL COMMENTS : <br /> PHASE :I GROUT INSPECTION r� PHASE LIF FINA INSPECTIO <br /> ip <br /> INSPECTION SY DATE MI6 INSPECTION BY DATE / <br /> / <br /> �H 1426 Pam- 12-.77 1`5, � r-- �� G�f� ��� 1/78 <br />