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SAN JOAQUIN LOCAL HEALTH DISTRICTOFFICE FOR USE:USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. -7-9-f©41 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT" Date..Issued `7.--(a `7 <br /> This .Permit Expires I Year From 'Date Issued ' <br /> LO�" . 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 I <br /> Joanuin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health j <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN Zg 0 <br /> i <br /> Owner' s Name Phone ; <br /> Address City <br /> Contractor' s Name License# v Phone <br /> = � 6 <br /> IS CERTIFICATE OF WORKMAN'S COMPENS O"1 TNSURA"!CE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ F RECONDITION ❑ DESTRUCTION❑ ` <br /> WELL CHLORINATION 0 WELL ABANDONMENT ED ; OTHER O <br /> PUMP INSTALLATION C7 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER"LINES PIT PRIVY n <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -, PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC T O <br /> Industrial Cable Tool Dia. of Well Excavation - i � <br /> �mestic/private Dr illed Dia. of Well Casing S <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout SealI <br /> Cathodic Protections $Qtary Type of- Grout <br /> Disposal Other Other Information , <br /> Geophysical - Surface Seal Installed b9: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I H.P. <br /> PUMP REPLACEMENT: MState-Work Done <br /> PUMP REPAIR: ❑State"Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe 'Matorial an2 Procedure <br /> tf <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 ch this permit is issued, I shall <br /> not employ any person in such manner as to be ome subJ t to Workman's Compensation <br /> laws of Cal fornia. " <br /> I WILL CALL 0 A GROUT INSPEC N PRIOR TO GROUTI WAND A F to <br /> I TION �i <br /> SIGNED TITLE• DATE: red <br /> (DRAW PLOT PLAN ON KVERX SIDE <br /> iv FOR DEPARTMEN ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE L �� <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE . INSPECTION BY )MAL DATE <br /> C4! 1A7G n.... 1n 77 y I"7o 1]1" <br />