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SAN JOAQUIN LOCAL HEALIH U15IKICI <br /> � `�0V �� <br /> FFICE USE: 1601 E. Hazelton .AVe. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 I <br /> =/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued7� -7� <br /> This Permit Ex• ires 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 o- 4-t6 CITY/TOWN <br /> Owner' s Name Phone — <br /> Address ;� City <br /> Contractor's Name License# =76/ Phone (, <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE OM FILE WITH SJLHD? YES NO <br /> TYPE OF WORK (Check) :` NEW WELL Q DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION C1 PUMP REPAIR LAY PUMP REPLACEMENT [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESe"0 1 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERS 0 <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 <br /> rrigation 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: Contractor <br /> Type of Pump H• <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: Q State Work Donedge-4-e o O <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 GROUT INSPECTION PRIOR TO- GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE. DATE: Z <br /> L DR W PLOT PLAN ON REVERSE SIDE F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE U1 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r DAT —3r <br /> EH 1426 Rev. 1247 118 2M <br />