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�. SAN JOAQUIN LOCAL HEALTH DISTRICT �7 <br /> Aw <br /> FOR OFFICE USE: +�A. E. Hazelton Ave. , Stockton, CA 95205 Permit No. / <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> - <br /> This Permit Expires I Year From Date Issued <br /> Complete In Triplicate ' <br /> Applicationishereby 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 /> CITY/TOWN <br /> EXACT STREET ADDRESS O � <br /> Owner's Name 1_` �,6- =11744) Phone ��- <br /> Address— A7 city ZL12P <br /> Contractor' s Name Z . Ci'4-LIN cense# � one <br /> IS CERTIFICATE OF WORKH'AN'S C011PENSATION IINSURAINCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN F-1RECONDITIONC] DESTRUCTION[D <br /> WELL CHL R NATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> -PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Cb <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <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 4) <br /> �omestic/private gilled 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 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and 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 /> 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 Californ 'a. " <br /> I WILL CALL A AzOOUT ,INSPECTIgh PRIOR TO GROUTING AND_441NAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PL T PL N ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE^6- .z 15�t-7_S_' INSPECTION BY DATE 7:2 <br /> ru i A9A Omit 19-77 117 8-- 2M <br />