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SAN JOAQUIN LOCAL :HEALTH DISTRICT EDateissued <br /> .zg1 - <br /> 1601 E. Hazelton .Ave. ,. Stockton, GA 95205 <br /> FOR OFFICE USE: Telephone: . (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> - a <br /> This Permit Ex fres l Year From Date ,Issue <br /> Complete In Triplicate <br /> made to the San Joaquin. Local: Health. Districdt,fure in ca peiance to <br /> hnSanuct <br /> p <br /> Application is hereby application is ma <br /> and/or install the. work herein described. This app <br /> ' ante No. i862� and the Rules and Regulations of the San Joaquin Local .Healt <br /> Joaquin County Ord <br /> Cistrict. QGCITY/TOKEN <br /> EXACT STREET 'ADDRESSPhone — <br /> / <br /> Owner' s Name tr s City Qe, ?f`� <br /> Address �Y 1111`? LicenseePhone -'17-� <br /> -� 1I ' d4 <br /> Contractor' s Name <br /> TS CERTIFICATE OF WORKMAN'S CO4`PENSATIO"! I"iSURA"ICE ON FILE WITH SJLHD? YES <br /> ' <br /> RECONDITION C3 _. DESTRUCTION. <br /> TYPO OF WORK (Check) : NEW WELL. <br /> DEEPEN ❑ WELL ABANDONMENT ❑ OTHER Ea <br /> WELL CHLORINAT L7 <br /> PUMP INSTALLATION Pk PUMP REPAIR❑ PUMP REPLACEMENT ❑ <br /> DIST TO NEAREST: SEPTIC TANKPIT 'PRIVY <br /> ' SEWER LINES OTHER_`_____ <br /> SEWAGE DISPOSA FIELD CESSPOOL/SEEPAGE PIT <br /> PUBLIC DOMESTIC WELL �— <br /> PROPERTY LINE. - PRIVAT DE DE OMEST,IC WELL 4 RUCTION SPECIFICATIONS (�r <br /> IW TYPE OF- WELL ,. <br /> INTENDED USE <br /> Cable Tool Dia. of Well Excavation t- <br /> Industrial Drilled Dia, of Well Casing <br /> 1 � Domestic/private Gauge of Casing <br /> ---7--Domestic/public Driven' "+ <br /> Gravel Pack Depth of Grout Se__a�___ <br /> k Irrigation . __._.` Rotary . _Type of Grout <br /> Cathodic Protection Other_______ Other Information <br /> Disposal Surface Seal Installed b <br /> M K s <br /> Geophysical <br /> I PUMP-, INSTALLATION: Contractor L H.P. <br /> Type c . Pu p , <br /> ! PUMP, REPLACEMENT; []State Work Done <br /> PUMP REPAIR: ❑State Work Done <br /> `. pth <br /> DESTRUCTION OF. WELL: Well Diameter <br /> Approximate DeD <br /> Describe Materia and Proce ure <br /> I <br /> lication and that the work will be done in accorda <br /> t I hereby certify that I have prepared this app <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Loc <br /> ' Health District. Home owner•-or--licensed agent' s signature certifies the following�.� shall <br /> 1 permit is issued—, <br /> "I certify that in the performance of ase too become subjectfor whichhis to Workman's Compensation <br /> not employ any person in such manner <br /> laws of California." <br /> I WILL CA L FOR A GROUT INSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. DATE,( ' - �r <br /> TITLE <br /> •SIGNED DR W PL L N ON REVER SIDE <br /> FOR DEPARTMENT U E ONLY <br /> PHASE I ' DATE 30 7� <br /> :• APPLICATION ACCEPTED BY r <br /> ADDITIONAL COMMENTS: _ PHASE. II ,FINAL -INSPECTION <br /> PHASE i I GROUS Il�SPECTION INSPECTION 'BY' DAT <br /> INSPECTION BY DATE <br /> 1/7:8 <br />