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Com !�° '�`� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFiC USE:ff <br /> 16Q1 E. Hazeltan Ave. , Stockton, CA 95205 Permit No.�i� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued _ <br /> This Permit Ex ires 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 /> EXACT STREET ADDRESS 2 a SCITY/TOWN , <br /> Owner's Name z Phone <br /> Address S' City ccs, <br /> Contractor's Namlicense Phone cam}. ?6 7rL <br /> IS CERTIFICATE OF WORKMAil'S 4P NSATIO�1 INSURANCE ON FILE WITH SJLHD? YES NO— <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION [] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR(@ PUMP REPLACEMENT Q <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 q,r <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 /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Ta ;ff�Aol H.P. <br /> / <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: 5dState Work Done _. <br /> DESTRUCTION OF WELL: Well Diameter XpproxFmate Depth <br /> Describe Material and Proce ure <br /> I hereby certify that I have prepared this application and 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 /> "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 14KECWOR TO GROUTING AND A FINAL INSPECTION. <br /> S I G N E a TITLE: ,&r DATE: <br /> (DRAW PL OT Dl-'All ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY VDATE 4 ? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ill FINAL INSPECTION fig <br /> INSPECTION BY DATE INSPECTION BY DATE — —? <br /> EH 1426 Rev. ' 12-77 1 /78 2M <br />