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T 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICEOR g5205 Permit Date Issued <br /> No. MS! <br /> FFICE USE: 1601 E. Hazelton Ave:, Stockton, CA Telephone: {209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> This Permit Ex fres i Year From Date •Issued i <br /> Complete In Triplicate <br /> Application is hereby mad to the San Joaquin Local Health District for a permit "to construct <br /> pliance with San <br /> and/or install the work h1 rein described. " This application is made in com <br /> Joaquin County Ordinance o. 1862 and the Rules and Regulations of the San Joaquin focal Health <br /> District. f +' , ,� + CITY/TOWN <br /> EXACT STREET ADDRESS ,. <br /> �+ rf <br /> Owner's Name ,> d Phone <br /> Address 'tflIlI , r" �r >- City <br /> Contractor' s Name r qu : +` +- License# . Phone <br /> IS CERTIFICATE OF WORKMAf. S C0IMPENSATIO'! It1SURA�lCE ON FILE WITH SJLHD? YES 1,40 <br /> TYPE OF WORK (Check) : N , WELL B-"' DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION C1WELL ABANDONMENT a OTHER ❑ ` <br /> PUMP INSTALLATION EF PUMP REPAIR❑ PUMP REPLACEMENT <br /> 0 <br /> DISTANCE TO NEAREST: S PTIC TANKU SEWER LINES PIT PRIVY. ✓j <br /> SEWAGE DISPOAL IELD CESSPOOL/SEEPAGE PIT OTHER N-1P 'OPERTY LINE -, PRIVATE DOMESTIC WELL. -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,/- Cable Tool Dia. of Well Excavation Ig-, <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 Protecti n Rotary Type of Grout 1,,' �- <br /> Disposal Other Other Information <br /> • - Geophysical - Surface Seal Installed b f s <br /> PUMP INSTALLATION: Contractor I H.P. <br /> T;�pe of Pump <br /> PUMP REPLACEMENT: State Work Done # <br />` PUMP REPAIR: State Work Done ' <br /> DESTRUCTION OF*WELL: Well Diameter i Approximate Depth <br /> 11 <br /> Describe Material and Proce ure <br /> I hereby certify that I t <br /> ave prepared this application and that the work will be done in accordancd <br /> with San Joaquin County rdinances ,^State Laws , and Rules and Regulations of the San Joaquin Local <br />' Health District. Home oner or licensed agent' s signature certifies the following: <br /> "I certify that in t1�te performance of the work for which this permit is issued, I shall <br /> not employ any persin in such manner as to become subject to Workman's Compensation <br /> laws of California <br /> I WILL CALL FOR A GRONJINSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 4- � ' � .��; : *� TITLE: DATE: � k <br />+ DR W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I I <br /> DATE S <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> f <br /> r . I ens n_-- 1A 77 '- - <br />