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SAN JOAQUIN'LOCAL` HEALTH DISTRICT <br /> EOR 'OFFICE USE: 1601 E. Hazel"ton .Ave. , .Stockton, CA 95205 Permit No.7 <br /> Telephone: (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 Gounty Ordinance No.` 1862 and the Rules and Regulations of the°Sari Joaqufn Local Health <br /> District. <br /> I 'EXACT STREET ADDRESS SO t CITY/TOW 6 0 l <br /> Owner'.s Name �� Phone --- <br /> -Address C , <br /> IContractor's Name Li censet2?& Phone <br /> :IS CERTIFICATE OF WORKMAN'S C01VV';PENSATION INSURANCE ON FILE�-WITH SJLHD? YES Y NO <br /> 4TYPEOF WORK (Check) : NEW WELL 0 DEEPEN RECONDITION' DESTRUCTION.[) - <br /> WELL -'CHLORINATION 0 -- -WELL ABANDONMENT O OTHER 0 <br /> PUMP INSTALLATION ED PUMP REPAIR_L . 'PUMP--REPLACEMENT <br /> DISTANCEJO NEAREST:. SEPTIC TANKS SEWER LINES . PIT PRIVY <br /> ,. SEWAGE DISPOSAL 1 FIEL p CES OL --:PIT OTHER =— <br /> a <br /> PROPERTY LINVO -EPRIVAESTIC WELL PUBLIC DOMESTIC WELL <br /> ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Too `Dia, of Well Excavation <br /> EERDomestic/private' Drilled Dia. of Well CasingQ " ro <br /> Dometic/public I Driven- Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout .Sea <br /> Cathodic Protection Rotary ...__,Type_of.- Grout <br /> Disposal4 Other Other Information <br /> Geophys cal , Surface Seal Installed by:__ <br /> PUMP. INSTALLATION: Contractor <br /> Type of Pump H.P. 4_ <br /> `.PUMP REPLACEMENT: []State Work Done <br /> Prl <br /> UMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia an Procedure <br /> �I I hereby certify that I havelprepared 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 became subject to Workman's Compensation <br /> laws of California." <br /> '°l WILL CALL FOR A GROUT9INWECTJOW PRIOR TO GROUTING AND A`FINAL INSPECTION. <br /> ; SIGNED TITLE: AlDATE: % <br /> i D PL L . ON REVERSE S D ' <br /> 1 FOR PfPARTMENT USE ONLY <br /> ''APPLICATION ACCEPTED BY D <br /> PHASE I.,.. ATE <br /> ADDITIONAL COMMENTS: <br /> PHAS "' II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /D / 7 <br /> �r;EH 14 26 Rev. /7$ R�- - Mg/- -`° <br />