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SAN JOAQUIN,_yLOC,AL HEALTH DISTRICT <br /> FQR-OFFICE USE: 1601 E. Hazelton Ave.', Stockton, CA 95205 Permit No. o <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <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 /> •' e_. , y,� / 1. �. ;. .f, CITY/TOWN.. - <br /> EXACT STREET ADDRESS,€ �i ; <br /> Owner's Name '1 ° Phone <br /> Address Ci tysFf �r <br /> Contractor' s Name ,, , ' :, 't - License#:LL, /Z/ Phone <br /> IS CERTIFICATE OF WORKMAN'S C01,1PENSATIOtI INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION F- WELL ABANDONMENT ❑ OTHER 0 � <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC- TAN ") 'f SEWER LINES ::;" !f PIT PRIVY � <br /> SWAGE' DISPOSAL FIELD : :;Y �_, . CESSPOOL/SEEPAGE PIT OTHER— I <br /> PROPERTY LINE ZZ'''PRIVATE DOMESTIC WELL---L ` I PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial '.Cable Tool Dia. of Well Excavation 141 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ti- --- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information/Zi, ;._;:. %. <br /> Geophysical Surface Seal Instal ed -by: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: OState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordant <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 P�AIOR TO GROUTING AND A FINAL INSPECTION. <br /> '! TITLE: ,-..� DATE:- , �.�t, <br /> SIGNED . ' '_ �._: <br /> 'DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I '� <br /> APPLICATION ACCEPTED BY DATEZ` ' <br /> ADDITIONAL COMMENTS : <br /> _ PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ru 1 nuc n,,,, 11_7.7 1/78 2M <br />