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+ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: /1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.Z-/ -iZ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued/ <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 `N <br /> 'oanain County Ordinance No. 1862 and the Rules and Regulations of the -San Joaquin Local Health <br /> District. R <br /> EXACT STREET ADDRESS - CITY/TOWN <br /> Owner' s Name ev Phone 1 <br />! Address -City <br />, Contractor's Name License# Phone N <br /> E <br /> IS' CERTIFICATE OF WORKMAN'S COMPENSATIO"! INSURA"lCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ W <br /> PUMP INSTALLAT�ON,�T- PUMP REPAIR❑ 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 -4 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1,4 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 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 CAL6 FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL-- INSPECTION. <br /> SIGNED TITLE: lql, DATE: <br /> DRAW PEOT PLAN ON REVERSESDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY-&, DATE� � <br />:ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP&010N PHASE III FINAL' INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Zo DATE Q- <br /> EH 1426 Rev_ 12-77 - -- -- - - 1 J 7 8 <br />