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FFICE USE: USAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 01 E. Hazelton. Ave. , Stockton, CA 95205 Permit No: 7 — Z <br /> MG Telephone (209) 466-.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> /d'3o61 7118 751 This Permit Ex ires.1 Year From Date Issued <br /> Complete In Triplicate x <br /> Application is hereby made to the San Joaquin Local Health District for a. permit to con <br /> and/or install the work herein described:. This a lication:3 San . <br /> Joaquin County Ordinance No. 1862'- and the ,Rules annd:Regulations�ofethe San pJoaquin wLocalaHeal-th <br /> District. <br /> EXACT STREET ADDRESS} 6 �� <br /> Owner's Name <br /> CITY%TOWN 1 <br /> Phone ' <br /> Address <br /> C.i ty. , <br /> Contractor's Name Ka Licens <br /> Phone <br /> ISTCRTIFICATE OF IJOCK�iAN'S CO"ZPENSATIO"! IPSU �A.NCE Odd FILE WITFI SJLHD? YES NO <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN [I . RECONDITION - -- r <br /> WELL CHLORINATION 0 WELL ABANDONMENT DEOTHER 0 [j .� <br /> PUMP INSTALLATION CI PUMP REPAIR❑" PUMP REPLACEMENT [] <br /> DISTANCE TO NEAREST: SEPTIC TANj+ �SEWER LINES�4 PIT PRIVY _ <br /> SEWAGE DIS S�FIELqCESSPOOL/SEEPA E PIT _,.___. OTHER <br /> PROPERTY LIN VO-'+RIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE � <br /> TYPE OF,-WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel] Excavation <br /> Domestic/private Oril_led Dia, of Well Casing �r� <br /> Domestic/public x Driven Gauge of Casing <br /> Irrigation ­,, Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -Rotary y . J Type of Grout n <br /> Disposal � � � ,,Other . <br /> Geophysical Other Informatio " <br /> "� Surface Seal Instal ed b <br />'IMP:-INSTALLATIA. �,'CbntraCtor <br /> _ Type of Pump H.P. <br />'UMP REPLACEMENT: []State Work Done 7 <br />'UMP REPAIR: <br /> __.., QState Work Done <br />'ESTRUCTION OF WELL: Well Diameter <br /> - Describe Materia an Proce 5- -re <br /> Approximate Depth <br /> hereby certify that I have prepared this application and that the work will be d <br /> ith San Joaquin County Ordinances, State Laws , and Rules and Regulations of the SaneJoaquinin oLocai�' <br /> ealth 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 /> WILL CALL FOR A ROUT P CT N RIOR TO GROUTING AND A FINAL INSPECTION. <br />[GNE r' <br /> TITLE: lzjrwDATE:q <br /> DR W PL T PL N ON REV R DE <br /> } <br /> EASE I FOR D PARTM NT USE ONLY <br />'PLICATION ACCEPTED BY DATE <br />)DITIONAL COMMENTS : <br /> PHASE I GROUINSPECTION PHASE III INAL INSPECTION <br /> SPECTION BY RATE - INSPECTION BY,/� DATE�o/�� <br />