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rt SAN JOAQUIN LOCAL HEALTH DISTRICTFOR LPemitNo.FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205Telephone:. (209) 466-6781e Issued <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 incompliance with San <br /> Joaquin County Ordinance No... 1862 and the Rules and Regulations of the .San Joaquin Local Health i <br /> n15triCt. <br /> EXACT STREET ADDRESS a CITY/TOWN <br /> i <br /> Owner's dame Phone <br /> Address z" city <br /> Contractor' s Name <br /> License Phone <br /> IS CERTIFICATE OF WORr1AN'S C01•1PENSATIO"t ItISURAFI ON FILE WITH SJLHD? YES =i0 � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT ❑ �4 <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES -[ PIT PRIVYPI OTHER <br /> SEWAGE DISPOS+� ELD CESSPOOL/SEEPAGE y <br /> PROPERTY LIN fi/ZLYPRIVA E DOMESTIC WELD =- 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 /> Irrigation _Gravel Pack Depth of Grout Seal_:" <br /> Cathodic Protection V Rotary Type of Grout <br /> Disposal Other Other Informattion <br /> Geophysical Surface Seal Installe : _ �ll� — <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> ❑State Work Done <br /> DESTRUCTION OF WELL: 11 Diameter �L L w proximate epth a <br /> NONE Lt. � cri be Materi a and Procedure <br /> 60 Al <br /> I hereby. certify that I havnt Y`epa"eTis alp0icatiori and that the work will be done in accordant <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 GR ItRPVTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: <br /> rDR W PLOT PLAN ON REVE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE �- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROU SPE TION PHASE IIT FINAL INSPECTION w-7 <br /> INSPECTION BY DATE ,Z 7 INSPECTION BY DATE <br /> ^� � �1/7 s 2� <br />