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J t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFICE USE:-., 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. 97 U f <br /> Telephone: (209) 466-6781 <br /> fi <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued - -� <br /> (Complete In Triplicate): a <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 This <br /> and Regulations of the San Joaquin Local Health <br /> District. <br /> r <br /> EXACT STREET ADDRESS J G CITY/TORN <br /> Owner's Name Phone <br /> Address -. : Ci ty. <br /> Contractor's Name 4 License# 6 Z3' _ Phone_3 6� ?- <br /> IS CERTIFICATE.OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH SJLHD? YES u N0 <br /> TYPE OF WORK (Check) : NEW WELL-0 DEEPEN ❑ RECONDITION Q DESTRUCTION CO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT-0 OTHER 0 <br /> €' PUMP INSTALLATION ❑ , :PUMP REPAIR❑ PUMP REPLACEMENT IR <br />'DISTANCE TO NEAREST:. �SEPT4-C TANK- E-R-L-NE-S "�'PlPRTI�Y <br /> SEWAGE DISPOSAL FIELD CES PYL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC 'WELL PUBLIC DOMESTIC WELL' <br /> - INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFICATIONS . <br /> Industrial , Cable Tool Dia. of Well Excavation <br /> Domestic/private '� Drilled ' Dia: of Well Casing <br /> ' Domestic/publl 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 /> ' 4 - Geophysical Surface Seal Insta ed b : <br /> I <br /> PUMP INSTALLATION: Contractor } f 1" w <br /> T Type of Pump H.P. <br /> PUMP REPLACEMENT: raState. Work Done <br /> PUMP REPAIR: Q State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter A <br /> Describe Materia an Procedure <br /> Approximate Depth <br /> 1 hereby certify that I have prepared this application and that`'the work will be done in accordance ! <br /> w1th San Joaquin County Ordinances, State Laws, and Rules and Regulations..of. the San Joaquin Local F <br /> Health District. Home owner. or licensed agent' s signature certifies the following:' <br /> t"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 ' E <br /> laws of California.".e <br /> I WILL CALL OR . GROUT SPECTION PFeIOR TO GROUTI G'­AND A MAC' INSPECTION. �w~ <br /> SIGNED TITLE: DATE: �p'`.� '�, 4 <br /> ON REVERS E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> A:P-L�ATION ACCEPTED BY� DATE 2r— # <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYD ATE - r <br /> EH 14 26 Rev. 9178 vI I 7 Ste' 2M' <br />