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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFiCE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit A. <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 <br /> W ► T- <br /> ..14 w Phont2�.g4L_552n <br /> gess City e <br /> Contractor's Name License# _ Phon��'.r71-'lI !�3 <br /> IS CERTIFICATE OF WORKMANIS COMPENSATION INSURANCE ON FILE WITH SJLHD? YESN0� <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCT IO [J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER (3l" fP-rs;m c- gshijt we'Sr <br /> PUMP INSTALLATION ❑ PUMP REPAIRM- PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT.,PRIVY <br /> SEWAGE-DISPOSAL IELD CESSPOOL/SEEPAGE Pte— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL.-�..� PUBLIC DOMESTIC WE—LL — <br /> USE <br /> E L .p <br /> INTENDED f1SE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> --- Cable ToolDia. of Well Excavation ;.• <br /> Domestic/private Drilled Dia, of Well Casing ? <br /> Domestic/public Driven Gauge of CasingdN r <br /> Irrigation Gravel Pack Depth of Grout Seeal � <br /> Cathodic Protection —Rotary Type of Grout tJ P <br /> Disposal Other Other Information o r ; <br /> Geophysical Surface Seal Installtd by: ' <br /> PUMP INSTALLATION: Contractor <br /> T <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work .Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 2 .5 rt <br /> Describe Material and Procedure . Approximate Depth o'— ' <br /> I hereby certify that I have prepared this application ,and that the work will be done in accordant <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 C if nia. " <br /> I WILL CALL OR OU <br /> SP CTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 7 <br /> �DRAW PL T PL N ON REVERSE SIDE <br /> PHASE IDEP TMENT USE ONLY <br /> TP—PLICATION ACCEPTEDBY P '� <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE iNSPEGTION BY ATE <br /> EH 14 26 Rev. 9 78 9/78 29 <br />