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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />—FOR OFFICE USE:, 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 71 - 3 d <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires I Year From Date Issued <br /> (Complete- In Triplicaste <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 Healt" <br /> District. <br /> EXACT STREET ADDRESS 9b3 6 \A1 CITY/TOWN c� <br /> Owner's Name Phone <br /> Address T City <br /> Contractor' s Name License#I°f'7S8b Phone ' <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL O DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT CI OTHER❑ <br /> PUMP INSTALLATION PUMP REPAIR CI PUMP REPLACEMENT Q <br /> s <br /> DISTANCE TO NEAREST: SEPTIC 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 /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed -by: <br /> PUMP INSTALLATION: Contractor 0 <br /> Type of- Pump -- - --yH/.P. ! .,S' - <br /> PUMP REPLACEMENT: Q State Work Done / c. 0,14,041 <br /> 7. <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter e?11 <br /> . Approxim to Depth <br /> Describe Material and Proce urezz A0 <br /> G' C ell o O <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 is d, I shall <br /> not employ any person in such manner as to become subject to Workman's CoNveation <br /> laws of California. " <br /> I WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: c '� <br /> (DRAW PLOT PLTN ON REVERSE DE <br /> FOR DEPARTNENT USE ONLY <br /> PHASE I <br /> I i <br /> APPLICATI N ACCEPTED BY ` ' DATE . — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION j3,„ PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY� ' DATE Z-L 9 <br /> "' <br />