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SAN JOAQUI-N,�LOCAL HEALTH DISTRICT <br /> JS E: 1601 E. Hazelton Ave:-,`Stockton, CA 95205 7Date,,I.ssued_a____/ <br /> o.7 _I.4 _ <br /> - Telephone (209)- 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP`PE,RMIT� <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 S. CITY/TOWN ; <br /> Owner's Name Phone <br /> Address , City <br /> Contractor's Name License��l/�/ Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIOM J� URAF4 E ON FILE WITH SJLHD°? YES 0 <br /> TYPE OF WORK (Check) : NEW WELL Rf DEEPEN ❑ RECONDITION d DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT [ V <br /> 'DISTANCE TO NEAREST: SEPTIC TANKZ Q ,� SEWER LINES/��� , PIT PRIVY _ a� <br /> SEWAGE DISPOS�I FIELD � f CESSPOOL/SEEPA�E PIT OTHER <br /> PROPERTY LINO?14PRIVAT�STIC 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 10 <br /> Domestic/public Driven Gauge of Casing <br /> I Irrigation =Gravel Pack Depth of Grout Sea r <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Insta ed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I� PUMP REPLACEMENT: t7 State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> jDESTRUCTION OF.WELL: Well Diameter '!),�u Approximate Depth �- <br /> Describe Materia an Procedure <br /> I hereby certify that I have prepared this application and that- the -work wi-l-1 be- done in accordanu <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 /> Taws of California.". - <br /> . 1 WILL CALL FORA ROV INPVfION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE: DAT£: <br /> LU I 1-1-AN ON REV£R E E <br /> OR ARTMENT USE. ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ,GROUT INSP PHASE I r;NR INSPECTIO <br /> 1INSPECTION BY DATE �' — INSPECTION BY ATE <br /> 7u ,d 9A Po„ a/71Q /78 2? <br />