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r <br /> SAN JOAQUIN, LOCA. HEALTH DISTRICT <br /> EOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: - (209) 466-6781 <br /> 4 APPLICATION FOR WELL±CONSTRUCTION OR PUMP PERMIT Date Issued-?,- <br /> �- <br /> L& This' Pe rmit Expires 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 .J.oaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS CITY/TOWN r <br /> Owner's Name Phone <br /> Address City <br /> Contractor' s Name .'License# / Phone_ Z Z f6 <br /> IS CERTIFICATE OF WORKMAN'S COMPENSA ION-`INSURANCE ON FILE WITH SJLHD? YESNO <br /> TYPE OF WORK (Check) : NEW WELL NATDEEPEN ❑ RECONDITION C3DESTRUCTION❑ <br /> WELL CHLOR ION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <br /> LA <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 SPECIFICAT ` <br /> Industrial Cable Tool Dia. of lel l—Ex-cavati on <br /> ©c Domestic/private Drilled Dia. of Well Casing _ <br /> omestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Cathodic Protection �8atary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.R. <br /> PUMP REPLACEMENT: E]State 'Work Done <br /> .f <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth, <br /> Describe Material an2 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 workfor c t 's permit is issued, I shall <br /> not employ any person in such manner as to becom subject o Workman's Compensation <br /> laws of California." <br /> I WILL CALL OR A GROUT INSPECTMN RIOR TO GROUTIN AND A F AL S TIO <br /> SIGNED TITLE: DATE4�1--2--/,2Z <br /> RAW PLOT PLAN ON REVEWE SIDE <br /> FOR DEPARTMENT U ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ���i��,, DATE, <br /> EH 1426 Rev. 12-77 _ _ 1I78 2M <br />