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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�L FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. '71-3-1-9 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /9- ? <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 ''& °fes �� , , CITY/TOwN r= <br /> Owner's Name -.. _ <br /> Phone .� . ,. �� � <br /> Address F, r - r� <br /> �` City <br /> Contractor's Name " f <br /> _ License# Phone_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD7 YES NO <br /> TYPE OF WORK (Check) : NEW WELL.M7m MDEEPEN 0 RECONDITIONDESTRUCTION ] <br /> WELL CHLORINATION I3 WELL ABANDONMENT Q mOTHER F <br /> PUMP INSTALLATION[] PUMP REPAIR M PUMP REPLACEMENT] <br /> DISTANCE TO NEAREST: ' m SEPTIC TANK SEWER 'LINES PIT PRIVY <br /> SEWAGE DISP S- AL FIELD CESSP OL/SEEPAGE PIT— OTHER <br /> PROPERTY L-INE' -•.PKIVATE- -U� STIC 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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> isposal Other Other Information <br /> Geophysical Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> RUMP-;REPLACEMENT: C]State Work Done F <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .l " p <br /> Approximate Depth_ <br /> Describe Materia -an- z Proce ure <br /> 0.f " �� <br /> I hereby certify that I have prepared this application and that the work will be done in ac.cordanc# <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations •of .the. San Joaquin Local <br /> Health 'Dimstri ct.`- Home owner or l itensed agent's s gn&ture -ce ti fi_e.s._the-fo l.owi ng_:. <br /> "I-�certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in suchmmman-her as to become subject to Workman S" Compensation <br /> laws of Cal ifernya.� <br /> I WILL CALL FOR A;<G_ROLf•INSPECTION PRIOR TO GROUTING AND A FINAL mINSPECTI.ON. <br /> SIGNED e.�.°���� DATE: <br /> , <br /> (DRAW +L TITLE: �`� <br /> PLAW TI REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY1/ 79 <br /> , <br /> APPLICATION ACCEPTED Blf �'� �, � ; ;, � : DATE <br /> ADDITIONAL COMMENTS: <br /> PH E II GROUT TNSPECTION PHASE- III INALmINSPECTION <br />[NSPECTiON BY DAT E--q 7 INSPECTION BY DATE eJ-a o -,2V <br />.H 14 26 Rev. 9/7f3 __ •�.. <br />