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SAN JOAQUIN .LOCAL- HEALTH DISTRICT ` <br /> FFICE USE: 1601 E. Hazelton,-Ave: , Stockton, CA 95205 Permit No.�1L=2em <br /> Telephone:, (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /Z <br /> ThisPermit. Ex i.res 1 Year„From Date Issued <br /> Complete In Triplicate <br /> Application is hereby made to the San Joaquin 1 Local Heal th, District for .a permit to at�:truct <br /> t <br /> and/or 'i nstal l the `work here-in descri bed'. This ,appl icat !on -is'. made in compliance with San , <br /> 'oaquin Coun'ty',0rdinahce. No. 1862 and the. Rul-es :and Regulattons of the Sari:-Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS. p R� ,�regn CITY/TOWNAiq <br /> Owner' s NamePhone <br /> .. 1 <br /> Address., �! <br /> r �. <br /> city <br /> Contractor's Name . cen, Li _., .. <br /> �_,c.�,,,.,�aJ s eO,3 2� Phone 4 4 �5 <br /> IS CERT_IFI-CATE OF WORKMIAN'S COMPENSATIO"1 I"1SURANCE ON FILE WITH SJLHD? YES � NO <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER❑ <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT <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 /> 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 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work DonepA,1,C�SW L—id <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 GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE: DATE: la-s!jR <br /> DRAW PLOT PLAN ON REVERSE IDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYl D TE <br /> ADDITIONAL COMMENTS: <br /> _PHASE II GROUT INSPECTION PH S II INYL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br />-u Tngg o,,., ' 1`1i 17 ..- ,.__:� . -_.. �. - - - 1 1-7Q err <br />