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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E- FOEROFF I C E..USE: , v 1601 E. Hazelton ve�,z Stockton, CA 95205 Permit No.-719-- 16� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued 2- <br /> p � 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 /> ,oanuin County Ordinance No. 1862 and the Rules and . Regulations of the San Joaquin Local Health. <br /> District. // L � � �..� <br /> EXACT STREET ADDRESS {p Q U CITY/TOWN <br /> Owner's Name Phone <br /> Address Gity. <br /> Contractor's Name . License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURAINCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ *o <br /> WELL CHLORINATION Q WELL ABANDONMENT--E3 OTHER 0 � <br /> PUMP INSTALLATION C! PUMP REPAIR❑ PUMP REPLACEMENT Ej <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 SPECIFIC IIS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> domestic/private Drilled Ria. 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 r <br /> Disposal ther Other Information <br /> Geophysical Surface Seal Installed 'bYy <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 <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 becomes c o Workman' s Compensation <br /> laws of California. ” <br /> I WILL CALL O A GROUT INSPECT"N PRIOR TO GROUTING ND A FI AL IN"EC <br /> SIGNEDTITLE: DATE�a <br /> �RWOT PL N ON R R SIDE <br /> PHASE I FOR DEPARTMENT ONLY <br /> APPLICATION ACCEPTED BY DATE" ~ 7,f-'" <br /> ADDITIONAL COMMENTS: <br /> i PHASE ,I-I WOUT INSPECTION PHASEjii FINAL INSPECTION <br /> INSPECTION BY DATEff-7— � '`INSPECTION BY ' klihDATE <br /> EH 1426 Rev.' 1.2=.=. 1/78 2M <br /> d <br />