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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F�L�LIFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 9520a ' Permit No. <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 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 'i <br /> Address- .` r ° -` -» �.,�• :, -C i <br /> Contractor's Name N , ,, r , �, Li cense Phone <br /> .,-- _ J, <br /> IS CERTIFICATE OF WORKMAN'S CO"IPENSATIO"! INSURANCE ON FILE WITH SJLHD? YES <br /> TYPE OF'WORK-(Check) : NEW WELL M"- DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ _. �_ ,�.WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT Q <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 Well Excavation <br /> 7 r Domestic/private Drilled Dia. of Well Casing y " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection _!A Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal ed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP-REPLACEMENT: p State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION -OF WELL: Well Diameter --Approximate Depthm==-:�- - -- <br /> Describe Material an2 Procedure <br /> I hereby certify that I have prepared this application and that the work wi.11 be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San' Joaquin Local3 <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 c;•� +,° ra ;r TITLEDATE: <br /> (DRAW PLOT TLEUN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7J/2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />=W 111•]G f]. 'In '7-7 <br />