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..SAN JOA QUIN LOCAL' HEF�LTH DISTRICT , Lit No <br /> Fog OFFICE USE: . <br /> 1601 E.. Hazel ton Ave. ,.Stockton CA ; .95205• , <br />- . Telephone: (209}' 't'66�6781 issued <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP' PERMIT <br /> This :Permit 11 Ex ,i-res I Year 'From'bate. Issued <br /> Complete .In Tri=plicate, <br /> E here made to the San- Joaquin 'Local Health District for a 'permit to construct <br /> Anpl'ication is e <br /> by',made <br /> and/dr. install . the work herein described.. This• andlReaul,a ions'ofethe SanpJoaquenwLoca1ahealth <br /> oagdi`n .Couot9 Ordinance 'No. '1862 and the Rules g ,. <br /> stri ct /TOWN <br /> r, CITY <br /> EX ACT=STREET. ADDRESS ' <br /> i <br /> Phone�� � ` <br /> owner''a5 'Name ;. <br /> ..City. <br /> 'Address' -- <br /> x . <br /> L'i cense'# �� Phone <br /> Contractor's Name. ; <br /> YS CERTIFICATE 'OF tJOi'K�tAtd''.S,:CO"PENSATIO`f I1SURA1,1C`E '•ON: F,ILE•'WITH SJLND? YES. ISO <br /> rYPEf <br /> OF .4,IORK (Check} ; NSW. WELLL DEEPEN,.0'', RECONDITION:[] DESTRUCTION Cl � a� <br /> WELL CHLORINATION.L 4IELL;ABANDONMENT 0 ,OTHER I� <br /> _ PUMP•REP'AI R Cj: ' PUMP,I REPLACEMENT C 1 <br /> rPl1MP• INSTALLA,TION � <br /> _ ' <br /> PIT— <br /> DISTANCE TO. NEAREST:' �"-SE.PT,IC TANK— SEWEf I�F1ES� <br /> SEWA6E< 0•ISPOSAL FIELD ^• CESPGO <br /> L/SEEPAGE PIT OTHER <br /> PROPERTY LINE ­PRIVATE .DOMESTIC WELL PUBLIC DOMESTIC°WELL+ <br /> _-, _ " ' _ CON` STR G ION SPECIFiCAT10N5..,, <br /> INTENDED:USE ... .• '. TYPE OF;WELL <br /> Dia. .-Of Well Excavation . <br /> Cable Tool' j <br /> Industrial � <br /> , - <br /> . Dia. of'We1;1. 'Casing <br /> Domestic/private Dr..i 11 ed <br /> a of Casing <br /> ^Domes tic/publ i.c • ven r ' Gau 9 <br /> ' --Ir'rigation - Gravel Pack depth of Grout 5ea'1 <br /> Cathodic Protection <br /> Rotary' -Type of Grout . <br /> Other Other :Inforniation= <br /> Geophysi cal <br /> Surface :Seal Installed b <br /> PUMP =INSTALLATION f +' ,•Con'tractor' - 5, H.P <br /> ; . I <br /> r Type :of .Pump <br /> PUMP :REPLACEMENT: . . _ �]State Work Done >. <br /> ' PUMP REP,4'IR: �� 0Sta.te Work-Done. <br /> i! y <br /> t <br /> DESTRUCTION OF' wELI': Well Diameter - Approximate, Depth <br /> "w-Dese-r-ii-be-rMa-te.r_i a- .and. Procedure <br /> a' tr <br /> I hereby certify that I have prepared: this app <br /> lication and that the work will`' be done in accordai <br /> wi tai San. Joac{ui n., .County Ordinances , State Laws , and :Rules' and Reg.ul ati ons• of the San Joaquin'Loc <br /> Health Di stri'c't`.' "Home„ owner or licensed agent' s signature certifies the. fol 1 owing.:ng <br /> F "I =certify -that i n the per"f�ormance,:'•of:the work for .whi ch thi s permi t `i s i slued, I s:hal 1 <br /> `n,ot :em'^I' 'zany person in-.su,ch.manner as; to, •b'ecdme sub'ject' to Workman's Compensation ,J <br /> 1aws"of,;tali:fornia:." .. • � <br /> I WIEC'CALFOR A' GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 'l f <br /> SIGNED <br /> " TITLE: DATE: <br /> ftRW PL T PL N ON REVE E SIDE�PLT <br /> F0ft DEPARTMENT USE ONLY -- <br /> y' PHASE I DATE `a-0 7 a <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION J <br /> . PHASE II GROUT INSPECTION <br /> INSPECTION BY _ DATE � ` INSPECTION BY _ DATE <br /> /78 .. 2 <br />