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SAN JOAQUIN LOCAL,,fKALTH U1SIRICT <br /> FOR -OFFICE .USE: 1601 E. Hazelton AveStockton, CA 95205 Permit No. <br /> Tel ephone: 009) -'466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit .Ek ires 1 YearFrom Date Issued <br /> Complete In jri p, i cat_e <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 Qrdinance No. 1862 and the Rules and, Regulations. of the :San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRES e on CITY/TOWN, <br />.*Owner' s Name Phoned -2y_ T_ <br />.Address _: y`�.. _ Ci t 5' %??.w <br /> City tai e_ e. <br /> Contractor's Name Licensee Phon ti <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIO"1 INSURA"! E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCT ION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR e� PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -0' SEWER LINES SSOO' � PIT PRIVY <br /> SEWAGE DISPOSAL IELD CES�L/SEEP�GE PIT OTHER <br /> PROPERTY LIN 0 RIVATE 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 /> rrigation 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. . <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: GRtate Work Don <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 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 CALL FOR-A GROUT INSPECTION PRIOR'.TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED~ TITLE: .titan- DATE: ZZb"Zzx, f <br /> DR W PLOT <br /> PLTN ON REV SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCE,PTED.1BY ( DATE <br /> ADDITIONAL COMMENTS : - <br /> PHASE . I .GROUT INSPECTION PHASE III FINAL INSPECTION F <br /> INSPECTION ..BY. _ DATE INSPECTION -BY�C cnu�_ DATE <br />