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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit N <br /> Telephone: (209)..,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued b / ` <br /> (Complete In Triplicate) , <br /> Application is hereby made to the San Joaquin Local Health District for a pernfit 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' Regu1ations of the San Joaquin- Local Health <br /> District. <br /> EXACT STREET ADDRESS - <br /> CITY/TOWN .g4C4L.0� , <br /> Owne'r's Name ! _ <br /> s Phone <br /> Address _ Ci.ty LsG A40 .✓ �- " <br /> Contractor's Name License# 79p/v Phone X38a � ~ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES O <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN ❑ RECONDITION [) DESTRUCTION[] <br /> WELL CHLORINATION <br /> 0 WELL ABANDONMENT 0 OTHER (0 <br /> PUMP INSTALLATION W PUMP REPAIRM"` \PUMP REPLACEMENT Q ac✓x��� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESf , P ff,PRIVY <br /> SEWAGE DISPOSAL FIELD CE5PSL/SEEP8GE PIT OTHER - - °4 <br /> ---- PR>FE'Y Llff� PR'TVATE--D MESTI=C WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE `'A`TY*E OF-WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> -------- Cable Tool Dia. -of-Well Excavation <br /> Domestic/private Drilled Dia. `rof2Well Ca3ins <br /> Domestic/public Driven Gaug4- of Casing <br /> _ Irrigation Gravel Pack Depth. of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> - Disposal Other Other Information <br /> Geophysical .� S rface Seal Insfin ed <br /> 'PUMP INSTALLATION: Contractor <br /> SG s ti —,. , <br /> Type of Pump r '� H.P. - <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> 'DESTRUCTION OF�WEL•L:--.�.-,Wel.l • Di"amet-er--m--•------- �`�� Approximate Depth <br /> Describe Materia and Proce ure , <br /> 'I hereby certify that I have prepared this application and that the workwill be done in accordant <br /> with' San Joaquin County Ordinances , State Laws , and Rules and Regulations of the: San Joaquin-Local <br /> Heal.th .District. Home owner.. o.r 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 F A GROUT N PECTION PRIOR TO GROUTING AND. F'I AL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PLO PL N ON REVS E SIDE <br /> PHASE I FOR DEPARTMENT -USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE IIL FINAL INSPEVION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH 14 26 Rev. .9/78 /7R , 9M <br />