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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 . Hazelton Ave. , Stockton, CA .x,05 Permit No. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -?-�- 7 <br /> This PermCit Ex .res 1 Year From Date Issued <br /> omplete 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 Xe� CITY/TOWN <br /> Owner's Name Phone <br /> Addresse-t-p-m-ecityx ti <br /> Contractor's Name E� ` r � Li cense# XGo f', Phone <br /> v� <br /> IS CERTIFICATE OF WORKHAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ 9 <br /> WELL CHLORINATION EI WELL ABANDONMENT O OTHER(-1 �^ <br /> PUMP INSTALLATION X) PUMP REPAIR 0 PUMP REPLACEMENT ❑ � <br /> s <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 We 1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information \ <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: ContractorK <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 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 GROU INSPECTION P IOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: 3 <br /> (DRAW PLT L N ON REVERSE SIDE <br /> FOR— DEPARTMENT USE ONLY <br /> PHASE I /,, � <br /> APPLICATION ACCEPTED BY----�/ '''� DATE 72'.5-- 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III PINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY4/ DATE 3—__S=77 <br />