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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />-.FQR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. U <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued %/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/car ;nstall 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 , r r CITY/TOWN,. ,. v __ <br /> Owner's Name F Phone :? _ <br /> Cit <br /> Address "� <br /> .-" r A <br /> �. <br /> Contractor' s Name ' �� , Li cense#. � r Phoney <br /> ,r <br /> IS CERTIFICATE OF WORKMAN'S COMIPENSATIOf! T'NSURAINCE ON FILE WITH SJLHD? YES IN <br /> TYPE OF WORK (Check) : NEW WELL[ DEEPEN ❑ RECONDITION [D DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 3` {- SEWER LINESf PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD ; ' . CESSPOOL/SEEPAGE PIT ., _. OTHER �. . <br /> PROPERTY LINF�4" PRIVATE DOMESTIC WELL42LL PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /,,� " _ N <br /> Domestic/private Drilled Dia. of Well Casing �Z� `' <br /> Domestic/public Driven Gauge of Casing ,', Z,-,,a:.,.,P z <br /> ' Irrigation Gravel Pack Depth of Grout Sha -- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information Z. ; :/, <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 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 FORA GROUT INSPECTIA" PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDy . �- - TITLE: '- . ,a, DATE: ,!(,. <br /> (DRAW PLOT PLAN ON REVERSE -SIDE ` <br /> FOR 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 INSPECTION BY DATE <br />=N1426 Rav_ 12-77 1/78 2M <br />