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SAN JOAQU1N LOCAL HEALTH DISTRICT <br /> FFICt US 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. _ <br /> Telephone: (209) 466-678I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued <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 /> ,oaqui n County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 0 � s U CITY/TOWN <br /> Owner's Name /1i Phone 835�5-- <br /> Address City <br /> Contractor's Name" License 2 Phone!j:a2 -/03� <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURA1110E ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN p RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Q OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEP`fIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY� LINE ,-. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Dostic/private Drilled Dia. of Well Casing & ' <br /> L,4155mestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection a L-R3fary Type of Grout <__ ,r,,'&,t,*- <br /> Disposal Other Other Information P-4-1 � <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump F —H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material arfd 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 F A T INSPECTION 0 T_ 0 GROUTING AND A FINAL INSPECTION. <br /> 5IGNED TITLE: DATE: <br /> (DRAW PLOT PLTN 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 I CTION BYE /. DATE_ — 7� <br /> EH 1426 Rev. 12-77 ---- -- 1 /78 2M <br />