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5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y---FOR OFFICE USE: 1601 E. HazeLto6 Ave. , Stockton, CA 95205 Permit No. 7e.,,l i l_7�_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT I 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 <br /> Joaquin County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS ? "_ .; : _. CITY/TOWN % <br /> Owner's Name Phone <br /> Address x �. „,r 1> / Ci ty <- . <br /> Contractor's Name f cA,:� ,� r . ., 9�i ;� s r Li cense#,.' Phone <br /> IS CERTIFICATE OF 140PKiiAN'S COMPENSATIO'I INSURANCE ON FILE WITH SJLHD? YES IV` I40 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN 0 RECONDITION ❑ DESTRUCTION[j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ <br /> PUMP INSTALLATION 0 PUMP REPAIR 0 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK -' , '�. SEWER LINES _ r_ `� PIT PRIVY -- . <br /> SEWAGE DISPOSAL. FIELDS . f1 CESSPOOL/SEEPAGE PIT - OTHER - - <br /> PROPERTY LIN8-'-.4PRIVATE DOMESTIC WELL,,"= PUBLIC DOMESTIC WELL -» <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ✓_�� '� <br /> k' Domestic/private Drilled Dia. of Well Casing « <br /> Domestic/public Driven Gauge of Casing ., . ; }� <br /> IrrigationGravel Pack Depth of Grout Seal. , r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: a 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 CALL FOR A GOUT'A NSP£ _ N-R'RTOR TO GROUTING AND A FINAL INSPECTION. # <br /> SIGNED '.;; "" �. '�,... •; TITLE: .6 �`. .r DATE: - <br /> .t DR W PLOT PLAN ON REVERSE SIDEw <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I F <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />