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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR <br /> -OFFICE USE: 1601 E. Hazelton Ave. ,, Stockton, CA 95205 Permit No. <br /> Telepho1.ne: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued S z� <br /> This Permit. Ex fres L 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 i.s made incompliance 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 ' 7 � an � i CITY/TOWN <br /> Owner' s Name /cam' Phone <br /> Addressr;ty <br /> Contractor' s Name License# � -3 Phone L — G 7 <br /> IS CERTIFICATE OF WORKPiAN'S !,1r SATIOf! INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL[] DEEPEN Cf RECONDITION DESTRUCTION C2 <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER 0 = <br /> PUMP INSTALLATION PUMP REPAIR 0 PUMP REPLACEMENT El <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 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 /> �c- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / - <br /> PUMP" REPLACEMENT: Q State Work Done <br /> PUMP RSR'-: QState Work Done <br /> DESTRUCTION OF WELL: Well Diameter pproximate Depth <br /> Describe Material anE Procedure <br /> I herebycertify that I have prepared this application and that the work will be done in accordance <br /> Y p p <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 /> Taws of California." <br /> I WILL CALL FOR A GROUT INS TI P 3 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNE ITLE: cc;g DATE: <br /> wl -(DRAW PLOT PLAINI ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> E PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IK FINAL INSPECTION <br />` INSPECTION BY DATE INSPECTION BY DATE <br />