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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ICE USE: 1601 E. Hazelton Ave. , Stockton; CA 95205 Permit No. <br /> Telephone: {209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP' PERMIT <br /> Date Issued <br /> This Permit Ex ires. l Year F.rom .Date Issued., <br /> �i Complete In Triplicate ` <br /> lApplication 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 -NoJ, 1862 and the Rules and Regulations of_ the .San- Joaquin Local Health <br /> ' 'District. <br /> EXACT STREET ADDRESS <br /> CITY/TOWN�c�? P4 <br /> Owner's Name V4 Phone <br /> AddressII <br /> .:• -. � C i ty� �� <br /> Contractor' s Name S License# Phone _ <br /> IS CERTIFICATE OF WORKMAN'S C01,14STIO,j INSURANCE ON FILE WITH SJLHD? YES-A- NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN O RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL, ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT �. <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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information-, <br /> I Geophysical Surface Seal Installed b : <br /> PUMP INSTALLATION! Contractor <br /> Type o;f Pump <br /> PUMP REPLACEMENT: a []State Work Done <br /> IPUMP REPAIR: State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Proce ure <br /> I hereby certify that I have prepared this applicati0n4and 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 /> "1 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. " I <br /> I WILL CALL FOR A GROUT INSPECTION PR <br /> R TO, G TING AND A FINAL INSPECTION. <br /> SIGNED 02- <br /> -/7 <br /> R T PL N ON RETERSE SIDE)— DATE. b <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r` DATE �, <br /> ADDITIONAL COMMENTS-: <br /> 117 k <br /> PHASE II GROUT INSPECTION PHAS II INSPECTION <br /> INSPECTION BY DATE INSPECTION BY G(I I <br />.FH 142A Rav 19_77. _ -- <br />