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C.o LSAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> F IGE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No <br /> Telephone: (209) 466-6781 <br /> Date IssuedS ,� <br /> APPLICATION FOR WELL CONSTRUCTION OR' PUMP PERMIT ' <br /> This. Permit Ex fres 1 Year From Date ;Issued <br /> Complete In .Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instal] the work herein described. This application is made in compliance with San <br /> Joaquin County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin- Local- Health <br /> District. <br /> EXACT STREET ADDRESS C3e�/ea CITY/TOWN <br /> Phone <br /> Owner' s Name <br /> .. -. City <br /> Address :. �o -.. Sp— <br /> Contractor's Name License# Phone <br /> I ION IESSURA"lCE Or, FILE 4lITf1 SJLHD? YE5 NO <br /> IS CERTIFICATE OF WORKMAN S CO P <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN Q- - RECONDITION 0 DESTRUCTIONd <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 _ — <br /> PUMP INSTALLATION El PUMP REPAIR[�] PUMP REPLACEMENT q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOLP <br /> / PIT 0 <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL y <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 /> Gauge of. Casing <br /> 9 <br /> i Driven 9 <br /> Domestic/public c <br /> Cx- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other information <br /> Geophysical Surface Seal Instal ed b <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: p State Work- Done <br /> PUMP REPAIR: W _ <br /> State Work Done � <br /> eF <br /> DESTRUCTION OF DELL: Well Diameter_. N Approximate Depth <br /> Describe Materia . and Procedure <br /> ^ 3 <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 , andiRules and Regulations of the San Joaquin- Local <br /> Health District. Home owner or licensed agen't' s signature certifies the following: ,L <br /> "I certify that in the performance of the'Work for"�ghich this permit is issued, I sha11 ` <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 INSPE ON PRI .R TO GROUTING AND A FINAL INSPECTION. <br /> ' SIGNED WL ( <br /> TITLE: R-&J DATE: <br /> DR : OTN REVERSE SIDE <br /> F R DEP RTMENT USE ONLY <br /> PHASE I DATE --� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHAS I IN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 5� <br /> 1 7 8' 1, 2M <br />