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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 1 Hazelton Ave. , Stockton, CA !�05 Permit No. 77-,5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Ex fires 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 /> 19 <br /> EXACT STREET ADDRES aQ 307 3 CITY/TOWN Xn e.,.e <br /> Owner's Name Phone <br /> Address city <br /> Contractor' s Name Name License#,Vo Phone �a3—mss/ti <br /> IS CERTIFICATE OF WORKIIAN'S COMPENSATION INSURA?ICE ON FILE WITH SJLHD? YESy NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ C <br /> PUMP INSTALLATION ❑ PUMP REPAIR.V PUMP REPLACEMENT ❑ 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER n <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 g <br /> Domestic/private Drilled Dia. of Well Casing C <br /> omestic/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 n <br /> Geophysical cj1/ 7.0 Surface Seal Ins al ed b <br /> PUMP INSTALLATION: Contracto <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 Proce ure <br /> I hereby certify that I have prepared this application and that the work will be done in accordan( <br /> with San Joaquin County Ordinances, State Laws , and Rules and Regulations of the San Joaquin Loca' <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 G UT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> DR W PL T PL N ON REVERSE SIDE <br /> F R DEP RTMENT USE ONLY <br /> PHASE I -„l, <br /> -VP—PLICATION ACCEPTED BY_ ,.��,.-L� DATE Sf <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III IIAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S2 f <br />