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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 79 -?I.7 <br /> J I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT SCANNED — <br /> 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 fjy <br /> Owner's Name M� .j Phone <br /> Address City <br /> Contractor' s Name License# Phone <br /> IS CERTIFICATE OF 1J0RK"1AN'S C01IPENSATIO'N I JSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ p <br /> WELL CHLORINATION ❑ WELL ABANDONMENT h( OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ 'PUMP REPLACEMENT 0 �J <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 /> Domestic/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: u._. <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 4W Gu��Pe� c''i"�.rc: •�' <br /> I hereby certify that I have prepared this application and that the work will be done in accordan <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loca <br /> Health District. Nome 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 „/i <br /> law of C ifornia . " �Y <br /> I WILL &8 SP TION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGN5b �.,.�' TITLE: DATE: <br /> s DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEP MENT USE ONLY <br /> PHASE /2I <br /> APPLICATION ACCEPTED BY ,_ ., DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE F N IN ECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> EH 14 26 Rev. 9/7 <br />