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SAN JOAQUIN LOCAL HEALTH DISTRICT Permit No' <br /> FOR F-FICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 <br /> Telephone: (209) 466-6781 Date Issued ��'' � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT <br /> This PermitEx fires 1: Year From Date .I`ssued <br /> Complete In Tri pl,i nate "N` <br /> Application is hereby made to the San Joaquin Local Health District �nrcomplianceit twithnSanuct <br /> pp <br /> and/or install the�rvork herein described. This application is made ,p <br /> and/osn County ordinance No. 1862 and the Rules and Regulations of .the, San Joaquin Local Health <br /> District. <br /> CITY/TOWN. <br /> EXACT STREET ADDRESS d Wy <br /> Phonel <br /> Owner' s Name <br /> 46 City <br /> Address _ <br /> Contractor's Name = License Phone <br /> IS CERTIFICATE OF WORKMAN'S C0MPENSATIO.j INStIRA"dCE OP1 FILE WITHSJLHD? YES ;10 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ❑ PRECONDITION C3 DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER MP REPLACEMENT <br /> PUMP INSTALLATION Qq PUMP REPAIR❑ PU .-.y <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES PIT PRIVY <br /> SEWAGE DISP SAL F ELD CESSPOOLLSEEPAGEPP��IC DOMESTICOTHERWEL� <br /> PROPERTY LINE -. PRIVATE DOMESTIC WEL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �Cab]e Tool Dia. of Well Excavation <br /> Industrial i <br /> ,Domestic/private Drilled Dia. of Well Casing <br /> Domestic%public Driven Gauge of Casing I11;:7_ <br /> Gravel Pack Depth of Grout Sealer <br /> Irrigation <br /> Cathodic Protection �XRotary Type of Grout/" <br /> Disposal Other _ _ Other Information <br /> Geophysical Surface Seal, Installed b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: . Q State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. �. Approximate Depth <br /> Descrikie 'Materia z-an vProcedure` ;b <br /> I hereby certify that I .have prepared th i sapp:l i_cati.on�and that;the work, w.i 1{1 be done in accordar <br /> with ,San Joaquin County Ordinances , State Laws , and Rules and Regula t�ons4of'''the" San Joaquin Loci <br /> Health District. Home owner or licensed atent s signature certifje:s ,the-,folTowang: <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' siCorpe 5 ation <br /> laws of California." <br /> � 1, WILL CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ISIGNED <br /> TITLE: DATE < <br /> DRAW PLOT PL,N ON REVERSE, SIDE <br /> FOR DEPARTME T USE ONLY <br /> ;PHASE I DATE ` 7� <br /> (APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE III TINAL INSPECTION <br /> `INSPECTION BY_r./ _. .DATE ��/- _ INSPECTION BY DATE y <br /> 781 / 21 <br />