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SAN JOAQUIN LOCAL HEALTH DISTRICT R. QFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,zg-f 5- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ ,2 <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 /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. ... <br /> EXACT STREET ADDRESS t CITY/TOWN <br /> . ..�. , �-� � <br /> Owner's Name ' y �- , ° Phone <br /> Address ell, + � � � z � City S4 <br /> Contractor's Name �. - ,' License#' Phone fb " <br /> IS CERTIFICATE OF WORKMAN'S CO"iPENSATIO,I T'NSURA"iCE ON FILE WITH SJLHD? YES 1110 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (,J <br /> r 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 Instal ed b-. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done. ` ` <br /> PUMP REPAIR: ❑State Work Done t <br /> DESTRUCTION OF WELL.: Well Diameter Approximate Depth <br /> Describe Material 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 FINAL INSPECTION. <br /> SIGNED �� '' o ? �.., TITLE: p DATE:_( 7-7� <br /> DRAW PLOT PLVN ON REVERSE SIDE <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I <br /> ADPL KATION ACCEPTED BY ,•� . ... +C - DATE 1 Z17 d <br /> ADDITIONAL COMMENTS : / <br /> PHASE II GROUT INSPECTION r PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />-EH 1426 ley_ 12-77 1/78 2M <br />