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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. f;25— <br /> r Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit. Ex fres 1 Year �FromComplete In Tripl <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 /> ,'oanuin County Ordinance 1862 and the Rules .and Regulations :of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ' <br /> CITY/TOWN -c_ <br /> Owner' s Name Phone Z9 3 <br /> AddressCity <br /> Contractor's Name AJ '9` License# Phone <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATIQ"t INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL[ DEEPEN 0 RECONDITION 0 DESTRUCTION❑ N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ® PUMP REPAIR❑ PUMP REPLACEMENT ❑ W <br /> DISTANCE TO NEAREST: SEPTIC TANK`740 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER F <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 S <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: ContractorS <br /> Type of Pump H.P._ <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: Q S ate Work Done r sT< fie <br /> 1� ��L -7OC <br /> DESTRUCTION OF WELL: We� Diameter �,- �Describe Materia Materia an Procedure Approxi a e Dep efo <br /> I hereby certify that I have prepared this application and that the work will be done in accordancE <br /> vith San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> iealth 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 /> L?o <br /> G T INSPECTIO PRIOR TO - RO TING AND A FINAL INSPECTION. <br /> r TLE: <br /> A L N EVER E -- DATE: /3 g <br /> HASE I FO DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL IN PECTION <br /> wSPECTION BY DATE INSPECTION BY ATE <br /> 1 1426 R _j <br />