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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 7 -�,2 <br /> Telephone: ' (209) 466--6781 :2- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex ices I 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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Distrjct. <br /> EXACT STREET ADDRESS �0 ��� �a~�-�-`~t�o�- / CITY/TOWN <br /> Owner's Name v, A14�P,4 Phone 36 f- ! SI a <br /> Address 4P�C City <br /> Contractor's Name'' License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Ea DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑�. L <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E] OTHER,( <br /> PUMP INSTALLATION Ea PUMP REPAIR❑ PUMP REPLACEMENT ❑ <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 t� <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 b <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 MateRal and 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 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A�, INAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DRAW- PLOT PLAN -ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �; ..cC L DATE .� <br /> ADDITIONAL COMMENTS : <br /> .PHASE Ii ROUT INSPECTION PHASE IU FINAL INSPECTION <br /> INSPECTION BY DATE INSP ON DATE <br /> E}_i 142fi. Rpw JP-77 �. <br />