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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1:601 Z. Hazelton Ave. , Stockton, CA 95205 Permit No.1$-1UI! <br /> . Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date�IsSuUN - -1�7 <br /> This Permit Expires 1 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 <br /> Address City <br /> Contractor' s Name ,4r �� License#` r�� Phone�� Z4, <br /> A <br /> IS CERTIFICATE OF WORKMAN'S CO"iPE SATIOi1 I-NSURAmCE ON. FILE WITH SJLHD? YES NO , <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION El PUMP REPAIR❑ PUMP REPLACEMENT Q i <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Cd <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 DONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �. .. <br /> Domestic/public Driven Gauge of Casing_ <br /> Irrigation Gravel Pack Depth of Grout ealt <br /> Cathodic Protection . ; Rotary Type of Grout ,.� _,;� <br /> Disposal Other Other Information <br /> ��R <br /> Geophysical Surface Seal Instal ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: C] State Work Done <br /> PUMP REPAIR: 0 State Work Done <br />)ESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> Mith San Joaquin County Ordinances , State Laws , and Rules and Regulations- of the San Joaquin Locall <br /> health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of t'he work for which this permit is issued, .I shall <br /> not emlYl°oy"*�any person in such manner as to become subject to Workman's Compensation <br /> I� laa s of Cal, fornia. " <br /> C Wi, L CALL FQAA GROUT INSPECTION RIOR TO GROUTING AND A FINAL INSPECTION' . <br /> TITLE: DATE:`' <br /> DR W <br /> PLOT PL N ON REVERSE .SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I F r <br /> APPLICATION ACCEPTED BY= .%:..-. , _ '� ` � `� , „� DATEt <br /> kDDITIONAL COMMENTS: ­w <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br />'H 1 APA Raw 19-77 1 /7A W I <br />