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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. —fS <br /> Telephone: (209} 466,6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued tY <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 /> EXACT STREET ADDRESS - �' %', , ,� a ,- CITY/TOWN . <br /> e _ <br /> Owner's Name;` ;� . � / Phonq. � ° ' r _ <br /> Addresses ., r ; :'` ;: �� - _ City <br /> Contractor' s Namez�& r r>�, ,� License#?:E ' / Phone_ <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION I`3SURANCE ON FILE WITH SJLHD? YES ;a0 <br /> TYPE OF WORK (Check) : NEW WELLM DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT CJ OTHER 0 <br /> PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS_ 4 SEWER LINEql:o 1 4. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD-:,; j. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINV'-; PRIV E DOMESTIC WELE/,' ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 121r <br /> _Domestic/private Drilled Dia. of Well Casing_ <br /> " <br /> Domestic/public Driven Gauge of Casing ,;-.4,. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information41 <br /> s <br /> Geophysical Surface Sear <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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.KIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED M, f /-,1,,r, <br /> .. ,, TITLE: <br /> DATE: r, <br /> DRAW PLO L N ON REVS E.'JSID <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE —r 3 <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />